PRELIMINARY TREATMENT PLAN Master Plan Internet		HUMBOLDT COUNTY HHS MENTAL HEALTH BRANCH / SEMPERVIRENS
PATIENT NAME Muriel P. James	ADMIT DATE November 14, 2005			DATE / TIME OF PLAN November 14, 2005 13:33 hrs
PRELIMINARY DIAGNOSIS from 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 1. Hello AMB Enter signs and symptoms or supporting data R/T Enter etiology 2. Altered Thought Processes AMB Enter signs and symptoms or supporting data R/T Enter etiology
3. 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
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

Client signature: Date:

PRELIMINARY TREATMENT PLAN

PATIENT Muriel P. James Admit Date: November 14, 2005

			[Name and Title]
	Special procedures for health and safety:
GOALS	Intervention		M M RN
			M M RN
	Medications:	Use this space to note any non-standard orders:	Name MD M M RN
	Medication dose ROUTE FREQUENCY
	Diet: Diet

PRELIMINARY TREATMENT PLAN

PATIENT Muriel P. James Admit Date: November 14, 2005

			[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: M M RN		Activity Worker Signature: Date: Name AT
		TREATMENT PLAN REVIEW: