Treatment plans are written documents which are a collaboration between the client and provider. Treatment plans are often considered “road maps” for care and outline how treatment will address symptoms and challenges using measurable goals and objectives. It’s a critical piece of the Golden Thread that creates a cohesive narrative of a client’s experience in an episode of care to provide clear evidence of medical necessity.
Every active client needs a treatment plan aligned with current diagnosis in their clinical record. When you reopen a client who was discharged from care, you must create a new treatment plan for the new episode of care.
The treatment plan includes information from the initial assessment such as diagnosis, primary presenting concern for the client, as well background information relevant to treatment. Treatment plans include SMART goals: Specific, Measurable, Attainable, Realistic, Time-specific.
At a minimum, treatment plans should be reviewed with clients and a treatment plan update completed within 6 months from the start of treatment. A review and update can also be conducted as early as 3 months. An annual treatment plan review and update is required for clients who remain in your care at 12 months.
As a resource for SonderMind providers, we’ve created a treatment plan template that you can access here.
To help you fill out treatment plan templates, we’ve also developed treatment plan examples featuring a fictional client. The information in each sample is for illustrative purposes only and does not contain real client information.
If you’re not a SonderMind provider, we invite you to join a community of mental health professionals who are dedicated to providing the highest-quality care and changing people’s lives. As part of the SonderMind community, you’ll have access to tools, resources, and support to provide the best care to your clients.
The Golden Thread: Using Medical Record Documentation Templates to Prove Medical Necessity
Initial assessment in the Golden Thread: Intake template
Documenting therapy sessions in the Golden Thread: Progress note template
Documenting end of care in the Golden Thread: Discharge summary template
**Disclaimer: This document is intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.
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