Treatment Plan

Treatment Plan

1. Modality

• Telehealth / In-person / Not discussed

2. Plan Details

• Plan date and scheduled review date
• Plan type: initial plan or review/update

3. Diagnostic Impression (With Code)

• Diagnosis as discussed, with DSM-5-TR or ICD-10 CM code
• Provisional or differential impressions recorded as such
• “Not discussed” where no diagnosis was raised

4. Mental Status Examination

Only domains observable in the session. One short clinical descriptor per domain, traceable to the session.

• Speech: rate, volume and fluency
• Mood: client’s report of mood, in their own words where available
• Affect: range and appropriateness of emotional response, noting any discrepancy with stated mood
• Thoughts: thought process and thought content
• Perceptions: any reported hallucinations or sensory misinterpretations, with type and impact
• Cognition: memory, orientation to time/place/person, concentration and comprehension
• Insight: understanding of own condition and symptoms, noting any lack of awareness or denial
• Judgment: decision-making ability and understanding of consequences

5. Presenting Problem

• Brief summary of behaviors, symptoms and functional impact
• Written to link to the diagnostic impression and support the clinical rationale for treatment
• Short descriptive phrases, no pronouns

6. Clinical Assessments / Measurement-Based Care

• Name of administered clinical measure and date of administration
• Results for each administration (initial or follow-up), including scores and any interpretative qualifiers
• Planned future administrations or frequency, if stated

7. Goals, Objectives and Interventions

For each numbered goal: the client’s stated goal in their own words, followed by the goal restated in clinical language using action verbs.

• Objectives: what the client will do — observable and measurable, using action verbs
• Interventions: what the clinician will do — named evidence-based techniques
• Target completion date or timeframe: whether a deadline or timeframe was set

8. Treatment Frequency

• Agreed frequency of sessions

9. Barriers / Strategies

• Barriers to implementing objectives or achieving goals, and how these were addressed
• Not included if not discussed

10. Coordination With Other Providers

• PCP, psychiatrist, school, allied health or other services involved
• What information will be shared, and with whose consent

11. Discharge and Transition Criteria

• Conditions under which treatment will conclude or step down
• Any planned transition or referral

12. Risk Assessment / Mitigation

• Risks identified in session, current risk level, and the agreed safety or mitigation plan
• Or confirmation that risk was explicitly screened for and denied
• Where no risk content is present, “Not discussed” is recorded

13. Collaboration and Agreement

• Whether the plan was developed with, and agreed to by, the client