A mental health treatment plan is a document that contains information about a patient's current mental health problems, as well as outlined goals and treatment for those disorders. To make this plan, the doctor needs to interview the patient. Using the information obtained during the interview, the psychotherapist draws up a treatment plan, which must be attached to the patient's medical history.
Step 1. Conduct a socio-psychological assessment
- Socio-psychological assessment is the process of gathering facts, during which a doctor (consultant, therapist, psychologist or psychotherapist) asks the client about his current mental problems, mental disorders in the past, family, current and past social problems at work, at school and in relationships with people. Also, during the assessment, the doctor checks the patient for problems with alcohol and drugs and establishes the fact of the consumption of psychotropic drugs that the patient has used or is still using. Most mental health institutions provide doctors with a template to use in the survey. The healthcare professional can also refer to medical history and other records during patient assessment.
- The counselor monitors the patient's physical condition and his / her relationships with healthcare professionals and other clients. The therapist assesses the patient's general mood (sad, angry, indifferent) and the reaction to the impact (how the patient expresses his emotions: frankly and intensely or practically does not express any emotions). These observations help the consultant to make the correct diagnosis and plan a suitable treatment plan.
Step 2. Discuss treatment goals with the patient
The treatment plan should be based on the client's opinion. The doctor and the patient decide together what are the objectives of the treatment and what are the methods of solving these problems
Step 3. Write a treatment plan
The treatment plan should include the information received from the patient, as well as the treatment goals set by the consultant together with the therapist. Many health care providers already have a special treatment plan form that the counselor must fill out. In the first part of the form, the consultant enters the symptoms of the patient. The form may also include space for the client to write down their comments about the treatment. The initial treatment plan is designed with both sides in mind
Step 4. Write down the details of your treatment plan
- At the very beginning, it is necessary to write the patient's diagnosis. The diagnosis is determined based on the patient's symptoms and how they compare with the criteria presented in the Diagnostic and Statistical Manual (DSM-IV-TR). This guide presents the American Psychotherapeutic Association (APA) diagnosis system. In terms of treatment, the diagnosis is divided into five parts. The first part includes the main diagnosis, reflecting the underlying mental disorder (major depression, schizophrenia, etc.) The coding of the first part of the diagnosis is needed to provide the patient with insurance benefits for the treatment of mental illness. The second part includes personality disorders (borderline personality disorder). The third part describes other illnesses the patient has, such as diabetes or heart disease. The fourth part includes the current psychosocial and social problems of a person (family conflicts, homelessness, and so on). The fifth part is the Global Assessment of Functioning (GAF) scale, which is a numerical assessment of the overall functioning of a person, considered in all aspects of his life. A rating from 91 to 100 indicates that the patient's mental and social functioning is at a high level. A rating from 1 to 10 means critically low performance, which is a threat to both the patient and those around him.
- The patient's symptoms and problems are rated on a scale from mild to severe. Symptoms that can be included in this section include depression, anxiety, appetite problems, and sleep disturbances.
- Medications prescribed for the treatment of general health problems and for the treatment of specific mental disorders should be indicated. Indicate the name of the drug, the required dose, the period of taking the drug and the prescription for the drug.
- A brief description of the patient's problems and symptoms should be included. This could also include your observations of how the patient behaved during the examination.
- The consultant must include the objectives and pathways of treatment, which must first be agreed with the patient. This can also include a form of treatment for solving the assigned tasks, such as individual or family treatment, the use of psychotropic drugs and medicinal substances.
- The plan should include dates on which additional check-ups will be performed to track the patient's progress in recovery. During these examinations, it will be necessary to make a decision whether to change the treatment plan or act according to the previously planned plan. The client and patient must sign a treatment plan.
- The client and patient must sign a treatment plan.