Essentials for More Effective Documentation Title: Treatment Plans Presented to Hagedorn Psych Hosp, NJ 8/08/06

I Introduction & Overview

Hagedorn Understand the current treatment planning process and pending improvements

JCAHO PC.4.10 Development of a plan for care, treatment, and services is individualized and appropriate to the patient's needs, strengths, limitations and goals.

CMS §482.61(c) Standard: Treatment Plan § (c)(1) Each patient must have an individual comprehensive treatment plan

Treatment & Planning

Treatment

Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person

Treatment Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person

Treatment Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person What are the person’s needs What is causing the need? What is the diagnosis, illness, disease, disorder

Treatment Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person What are the priorities? What is the most appropriate treatment for the identified needs? How are we going to provide that treatment?

Treatment Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person Providing the treatment Monitoring the effects and results of the treatment Refining treatment as needed (i.e., review & update)

Treatment Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person

Treatment Dx/Cause/Need Patient Assessment ID/Plan Treatment Treat/Monitor Person Determine the diagnosis, underlying cause of concerns and what is truly needed by the patient Collect data Identity appropriate treatment and plan how to implement it. Implement treatment and monitor effects/results

Documentation

Treatment Plans Goals Tx Plan Problem List Objectives Interventions Outcome An accurate guide to and description of treatment

Treatment Plans Goals Tx Plan Problem List Objectives Interventions Outcome Reflects the reasons for hospitalization Best when stated specifically, behaviorally Symptom vs. cause … as demonstrated by

Treatment Plans Goals Tx Plan Problem List Objectives Interventions Outcome Patient state Usually longer term Sometimes stated in global terms Pt will …

Treatment Plans Goals Tx Plan Problem List Objectives Interventions Outcome Patient state Usually shorter term Steps to goal achievement Best when specific and behavioral Pt will … … as indicated by

Treatment Plans Goals Tx Plan Problem List Objectives Interventions Outcome Staff action Something that achieves a patient objective Best when focus and frequency are specified Staff will …

Treatment Check Goals Tx Plan Problem List Objectives Interventions Outcome If accomplished would remove the need for hospitalization Reflects the reason(s) the pt needs hospitalization If accomplished would achieve identified goal(s) If performed with reasonable effectiveness would achieve an objective.

Reviews Goal accomplished Patient is regressing Patient fails to progress Needs a new goal Must review Treatment Plan When: