MASTER TREATMENT PLAN

Preliminary Plan

Internet

HUMBOLDT COUNTY HHS MENTAL HEALTH BRANCH / SEMPERVIRENS

PATIENT NAME Ani P. Bani

ADMIT DATE August 14, 2003

DATE / TIME OF PLAN August 14, 2003 12:25 hrs

DIAGNOSIS from psychiatric evaluation: AXIS I Enter Axis I Diagnosis

AXIS II Enter Diagnosis

AXIS III Medical condition

AXIS IV Letter codes: / describe stressors

AXIS V Current GAF / Highest GAF - Past Year

STRENGTHS From Psychiatric Evaluation [MD]

From Admitting Nursing Assessment [RN]

From Social Service Evaluation, Item 3h [SW]

IDENTIFIABLE DISABILITIES From Admitting Nursing Assessment [RN]

From Social Service Evaluation, Item 3h [SW]

ELOS Expected length of stay from psychiatric evaluation

PROGNOSIS From psychiatric evaluation

 

Problem / Reason for Hospitalization

1.   Show medical necessity: 5150 criteria  AMB Enter signs and symptoms or supporting data  R/T Enter etiology

2.   Show treatment of an approved DSM IV Diagnosis  AMB Enter signs and symptoms or supporting data  R/T Enter etiology

3.   Frequently occurring issues  AMB Enter signs and symptoms or supporting data  R/T Enter etiology

4.   Other problems  AMB Enter signs and symptoms or supporting data  R/T Enter etiology

5.   Other problems  AMB Enter signs and symptoms or supporting data  R/T Enter etiology

6.   Other problems  AMB Enter signs and symptoms or supporting data  R/T Enter etiology

7.   Medical Concerns:   a. Enter Med Concern   b. Med Concern   c. Med Concern   d. Med Concern   e. Med Concern

Long Term Goals [Discharge Objectives]

1. State goal in objective terms Time Frame

2. State goal in objective terms Time Frame

3. State goal in objective terms Time Frame

4. State goal in objective terms Time Frame

5. State goal in objective terms Time Frame

6. State goal in objective terms Time Frame

 

Short Term Goals

Target Date

Date Met

1. State goal in objective terms Time Frame

Enter Date

 

 

2. State goal in objective terms Time Frame

Enter Date

3. State goal in objective terms Time Frame

Enter Date

4. State goal in objective terms Time Frame

Enter Date

5. State goal in objective terms Time Frame

Enter Date

6. State goal in objective terms Time Frame

Enter Date

 

Client signature:                                                                                                                                                  Date:


 

MASTER TREATMENT PLAN

PATIENT Ani P. Bani                                                                                                              Admit Date: August 14, 2003

 

[Name and Title]

 

Special procedures for health and safety:

 

GOALS

Intervention

Name RN

    

    

           

    

    

           

 

Medications:

Use this space to note any non-standard orders:

Name MD

Name RN

 

Medication dose ROUTE FREQUENCY

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

 

 

 

Diet:

Diet

 

 


 

MASTER TREATMENT PLAN

PATIENT Ani P. Bani                                                                                                              Admit Date: August 14, 2003

 

[Name and Title]

 

Discharge and aftercare plans:

Name LCSW

GOALS

Enter first intervention

 

    

    

 

    

    

 

    

    

 

    

    

 

    

    

 

 

 

 

 

Plans for Continuing Care:

Name LCSW

GOALS

Enter first intervention

 

    

    

 

    

    

 

    

    

 

    

    

 

    

    

 

    

Activities:

Name AT

GOALS

Enter first intervention

 

    

    

 

    

    

 

    

    

 

 

 

 

MD Signature:                                                                   Date:

Name MD

Social Worker Signature:                                          Date:

Name LCSW

Nursing Signature:                                                            Date:

Name RN

Activity Worker Signature:                                       Date:

Name AT

 

TREATMENT PLAN REVIEW: