MASTER 1TREATMENT PLAN

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HUMBOLDT COUNTY HHS MENTAL HEALTH BRANCH / SEMPERVIRENS

PATIENT NAME Mary A. Samuelson

ADMIT DATE 3/10/06

DATE / TIME OF PLAN 3/13/06 22:25 hrs

DIAGNOSIS (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 [SW]

IDENTIFIABLE DISABILITIES From Admitting Nursing Assessment [RN]

From Social Service Evaluation [SW]

ELOS Expected length of stay from psychiatric evaluation

PROGNOSIS From psychiatric evaluation

 

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                        

Long Term Goals [Discharge Objectives]

1. State goal in objective terms   24 hrs before dc

2. State goal in objective terms   24hrs before dc

3. State goal in objective terms   24hrs before dc

       

       

       

 

Short Term Goals

Target Date

Date Met

1. State goal in objective terms   Within 48 hrs

3/15/06

 

 

2. State goal in objective terms   Within 48 hrs

3/15/06

3. State goal in objective terms   Within 48 hrs

3/15/06

       

 

       

 

       

 

 

Client signature:                                                                                                                                                  Date:

 

MASTER TREATMENT PLAN

PATIENT Mary A. Samuelson                                                                                                              Admit Date: 3/10/06

 

[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

 

 

 

MASTER TREATMENT PLAN

PATIENT Mary A. Samuelson                                                                                                              Admit Date: 3/10/06

 

[Name and Title]

 

Discharge and aftercare plans. Staff SW will:

Name LCSW

GOALS

Enter first intervention

 

    

    

 

    

    

 

    

    

 

    

    

 

    

    

 

 

 

 

 

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: