Treatment Plan

Dx, presenting problems, strengths, barriers, medical necessity, goals, measurable objectives, and baseline measures.

Interventions, responsible provider, frequency, target date, review date, discharge criteria, and crisis plan.

Baseline measure:

Crisis / safety plan reference:

Patient / guardian signature and date:

Clinician signature and date:

Plan and Follow-Up

Focus	Documentation
Problem / goal	Define active problem, baseline severity, long-term goal, measurable objective, and target date. Problem / baseline: Goal: Measurable objective / target date:
Intervention	List modality or protocol, responsible clinician, frequency, patient tasks, and coordination. Interventions: Responsible party / frequency: Patient tasks / coordination:
Review	Set review date, outcome measure, discharge criteria, and revision triggers. Outcome measure: Review date: Revision / discharge criteria:

Focus

Documentation

Problem / goal

Define active problem, baseline severity, long-term goal, measurable objective, and target date.

Problem / baseline:

Goal:

Measurable objective / target date:

Intervention

List modality or protocol, responsible clinician, frequency, patient tasks, and coordination.

Interventions:

Responsible party / frequency:

Patient tasks / coordination:

Review

Set review date, outcome measure, discharge criteria, and revision triggers.

Outcome measure:

Review date:

Revision / discharge criteria: