PRELIMINARY 1TREATMENT PLAN Internet		HUMBOLDT COUNTY HHS MENTAL HEALTH BRANCH / SEMPERVIRENS
PATIENT NAME First M. Last	ADMIT DATE 2/8/07			DATE / TIME OF PLAN 2/8/07 22:11 hrs
PRELIMINARY DIAGNOSIS (admission orders) Enter provisional Axis I diagnosis
STRENGTHS ____________________ [MD]		From Admitting Nursing Assessment [RN]			____________________ [SW]
IDENTIFIABLE DISABILITIES From Admitting Nursing Assessment [RN]						____________________ [SW]
ELOS ____________________			PROGNOSIS ____________________

Problem / Reason for Hospitalization (prioritized) 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. Medical Concerns: a. Enter Med Concern b. Med Concern
Long Term Goals [Discharge Objectives]
1. State goal in objective terms 24 hrs before dc 2. State goal in objective terms 24 hrs before dc 3. State goal in objective terms 24 hrs before dc
Short Term Goals	Target Date	Date Met
1. State goal in objective terms Within 48 hrs	2/10/07
2. State goal in objective terms Within 48 hrs	2/10/07
3. State goal in objective terms Within 48 hrs	2/10/07

Client signature: Date:

PRELIMINARY TREATMENT PLAN

PATIENT First M. Last Admit Date: 2/8/07

								[Name and Title]
	Special procedures for health and safety. Nursing staff will:
LTG #1	Intervention							Name RN
LTG #2	Intervention
LTG #3	Intervention
MEDICATIONS: MD will prescribe and nursing will administer medications. Both disciplines will monitor and assess for efficacy and adverse side effects								Name MD Name RN
Medication		Dose	Route	Frequency	Medication	Dose	Route		Frequency
Zyprexa Zydis		20 mg	PO	BID
Use this space to note any non-standard orders:
Diet: Diet

PRELIMINARY TREATMENT PLAN

PATIENT First M. Last Admit Date: 2/8/07

			[Name and Title]
	Discharge and aftercare plans. Staff SW will:		Name LCSW
GOALS	Obtain releases of information for PMD, family, significant other, to gather information and make discharge and aftercare treatment plans
	Plans for Continuing Care. Staff SW will:		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: