Treatment plan notes are one of many types of therapy notes. A patient's treatment plan should be thought of as a collaborative roadmap that communicates exactly why your patient is in therapy and how you are going to treat them. Treatment plans typically contain problems, diagnoses, goals, interventions, life changes, breakthroughs and, potentially, setbacks along the way. With all that information, how exactly should a treatment plan be structured? Let's dive into the various moving parts of a patient treatment plan, what it should achieve, some tips to follow when making one, and treatment plan template examples created using Vagaro’s mental health software.
Why Use a Mental Health Treatment Plan?
Their usefulness in mental health care is self-evident, but let's recap the major benefits of effective patient treatment plans.
For patients, a mental health treatment plan:
- Keeps them engaged during therapy, giving them room for their opinions, feelings, thoughts and experiences.
- Helps them break through barriers to their wellbeing by breaking treatment down into attainable goals.
- Helps them visualize their path and see the progress they’ve made along the way.
- Improves their communication skills by making them voice their needs, wants, concerns and goals.
For you, a mental health treatment plan:
- Improves mental health practice efficiency by adding organization and structure to appointments.
- Provides reference points for treating future patients and effective therapy frameworks and modalities over time.
- Helps ensure you are properly reimbursed for services in case of an insurance audit.
- Demonstrates your logic and expertise as a mental health professional in case of legal situations involving your patient.
Of course, none of this is true unless your mental health treatment plans are detailed, organized and dynamic. Let's see what that would look like:
Mental Health Treatment Plan Template (Example)
Mental health practice management software, like Vagaro’s, offers a versatile, HIPAA-compliant forms builder tool that enables you to create custom treatment plans that are easy to read, and revise, as necessary. Its drag-and-drop functionality is intuitive and easily editable to accommodate any changes you need to make. Once created, they can be stored neatly and securely in the patient’s profile with all their necessary information.
The counseling treatment plan example below was made using Vagaro’s Forms feature:
Remember that every patient is different. One may have multiple diagnosed mental health problems, such as substance abuse disorder and major depressive disorder and will have multiple goals to work towards as a result. You may also include a section for assessment scores, such as the Generalized Anxiety Disorder Screener (GAD7), the Depression Anxiety Stress Scale (DASS), or the Beck Depression Inventory (BDI-ii).
Parts of a Patient Treatment Plan Explained
As you can see, patient treatment plans have several components, and may evolve as therapy progresses. Modifications to the plan may need to be made based on patient feedback and your own clinical judgment.
For these reasons, no two mental health treatment plans are alike. That said, let's break down each treatment plan section shown in the above example:
1. Patient’s Information
Very simple. This section is for your patient’s basic personal, demographic & insurance information.
2. Reported Problem, Assessment or Ailment
This section includes a summary of your patient’s presenting mental health issues, impairments and diagnoses, if applicable. You can also use this space to describe relevant personal and medical history and assess your patient’s problems.
3. Interventions & Strategies
This is prescribed treatment by you, the mental health professional. This part will detail the therapeutic modality you use towards your patient’s treatment goals. It may include various evidence-based interventions like cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), psychodynamic therapy or mindfulness practices.
4. Major Treatment Goals
This is where you’ll list specific, measurable, achievable, relevant, and time-bound (SMART Goals) treatment goals. Goal setting should relate to the patient’s concerns and offer a clear direction for therapy. For example, major goals may include reducing anxiety symptoms, improving coping skills or enhancing communication. You can include both short-term and long-term goals if you think it’s necessary.
5. Therapy Objectives
Objectives should be specific, measurable steps that are relevant to your patient’s treatment goals. These objectives should be challenging, though achievable, and mutually agreed upon by you and your patient. For example, if a treatment goal was to reduce anxiety symptoms, a reasonable first objective might be for your patient to learn deep breathing, or meditative exercises, in which they will engage for 10 minutes a day over a four-week period to better manage their symptoms. At the end of that period, you’d report on their progress. An intermediate goal may be to have a patient attend a support group, as this would ease them out of their comfort zone to engage meaningfully with a room of new people.
6. A Timeline for Progress
A timeline of progress provides a visual representation of your patient’s expected journey through therapy. It outlines expected progress, helps both of you track expected milestones for each goal and objective, and assesses whether therapy is on track to meet established goals. These timelines can be adjusted throughout therapy based on your patient’s overall progress and shifting needs.
7. Major Treatment Milestones
Identify major milestones or accomplishments expected to occur during the therapy process. This provides an indicator of a patient’s growth and gives you the chance to celebrate a patient’s wins, which keeps them motivated to continue therapy faithfully.
8. Progress Evaluation
This is where you specify evaluation points and methods to assess your patient’s progress toward meeting their goals. This may involve regular progress check-ins at the beginning of each session; patient feedback and or symptom reassessments, wherein you reevaluate the severity and frequency of your patient’s symptoms related to their diagnosis and treatment goals, among others.
9. Progress
Finally, this is where you will record your patient’s achievements, challenges, and overall growth during therapy. Summarize notable developments, improvements, or breakthroughs observed during therapy.
Mental Health Treatment Plan Tips
Now that you know what each section of an effective treatment plan should address and you have a mental health treatment plan template to follow, keep the following tips in mind the next time you create one:
- Make sure that the treatment you bill insurance companies for matches what is written down in your mental health treatment plan.
- Insurance companies may only reimburse for certain treatments and diagnosed conditions, like major depressive disorder, which is why having a section for assessment results can be useful.
- Treatment plan goals are good, but too many can overwhelm even the best of us. Don’t exceed three goals to work toward at any one time. Add more to the plan later if it’s necessary—after your patient has achieved their initial goals.
- Set goals that are measurable, attainable and motivational for your patient. This ensures that they stay willing participants in their mental health treatment.
- As with treatment goals, keep a reasonable number of attainable objectives and set reasonable completion dates for each. This helps keep patients focused and motivated and can determine the viability of the objective toward the greater goal. Remember that your time frame for each objective can be adjusted if necessary.
- Like goals and objectives, make sure that a client’s progress is measurable and that your patient understands how it is being measured.
- Make sure that your progress notes align with patient goals and objectives. They should illustrate your clinical judgement and the clear steps taken toward meeting objectives.
- Refer to your patient’s mental health treatment plan regularly to ensure that you stay focused on patient goals during therapy sessions.
- They may not be necessary, but consider sections that outline steps to take in case of a mental health crisis; how you’ll collaborate with other healthcare providers, such as psychiatrists or medical doctors; or steps for how you will end therapy if the need arises. These are especially useful is you provide telehealth treatment.
Organized, thorough mental health treatment plans act as guides to success in therapy. Like SOAP Notes and other therapy note types, they help you deliver better care, improve patient engagement and help you run a more efficient private practice. They also provide a record that shows you followed all necessary procedures in providing patients with the highest quality of care. Vagaro's custom forms creator is an invaluable tool for mapping a patient’s treatment and charting their progress. Those tools, and many more, are within reach for mental health professionals who want to run a better, more efficient & streamlined practice. Start your FREE 30-day trial and experience it for yourself.