Road map for care in the Golden Thread: Treatment plan documentation template

Friday, September 22

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.


When should I use a treatment plan?

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.


What's in the treatment plan?

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.


How often does a treatment plan need to be reviewed?

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.

How can I get a copy of the treatment plan template?

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.

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You might also want to read

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

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