Master Treatment Plan - DOC

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					                                           MASTER TREATMENT PLAN

                                                         Diagnosis
Axis I:
Axis II:
Axis III:
Axis IV (list stressors):
Axis V (current GAF):

REASON FOR ADMISSISON:




STRENGTHS AND ASSETS (what positive behaviors/background does the patient have which can help
him/her recover?):




What special factors should be considered when planning for the learning needs of this patient? (Include barriers
to learning such as MR, physical disabilities, inability to read and understand instructions, actively psychotic,
needs 1:1, etc.):


List cultural factors affecting treatment (language, religious beliefs, cults, socioeconomic factors, etc.):


CRITERIA FOR TERMINATION OF TREATMENT (conditions necessary to discharge/transfer):




SUBSTANCE ABUSE:



                                                            I.D.


SCDMH FORM
MAY 80 (REV MAY 2011) M-203G Pg. 1 of 3
MH-FCC-2
                                                                     Master Treatment Plan

      Treatment                                                            Goals                                     Intervention/
      Dimension                                                                                                        Provider
                                                                                                                      Frequency
                                                                                                                   (see code sheet)
                                                             Time
                                         Problem Statement   Frame                 Statement of Goals/Objectives
     1. Medical -
        Psychiatric

     2. Medical -
        Physical



     3. Medical -
        Addictions

     4. Residential




     5. Other




                                                                                                    I.D.

SCDMH FORM
MAY 80 (REV MAY 2011) M-203G Pg.2 of 3
MH-FCC-2
Codes for Interventions and Providers
  Group                                     Description                      Group                     Description
  Code                                                                       Code
    1         Health & Fitness/ Nsg                                           27      Life Skills/ Nsg
    2         Discharge Group I/II SW                                         28      Sleep Promotion/ Nsg
    3         Health Education-HTN / RN                                       29      Anger Management/ Nsg
    4         RBT II/ CC/ RN                                                  30      Recover for Life / SHARE
    5         Skills for Recovery/ PSY                                        31      Expressive Arts/ AT
    6         Communication-Conversation/ Nsg                                 32      R.T. Socialization/ AT
    7         Relapse Control/ CC/ RN                                         33
    8         Medication Education/ RN                                        34      Weight Management/ AT
    9         Socialization/ Nsg                                              35
   10         Current Events/ Nsg                                             36      Team A Psychiatrist/ MD
   11         Patient Education Substance Abuse/ Pt. Ed.                      37      Team A Social Worker/ SW
   12         Better You, Better Me/ AT                                       38      Team A Psychologist/ PSY
   13         Avoiding Crisis Situations/ Nsg                                 39
   14         Spiritual Consultation/ Pt. Ed.                                 40      Team B Psychiatrist/ MD
   15         Leisure Ed/ AT                                                  41      Team B Social Worker/ SW
   16         Coping Better/ Nsg                                              42      Team B Psychologist/ PSY
   17         Tolerating Distress/ PSY                                        43
   18         Cognitive Enhancement/ Nsg                                      44      Team C Psychiatrist/ MD
   19         Health Education-Diabetes/ RN                                   45      Team C Social Worker/ SW
   20                                                                         46      Team C Psychologist/ PSY
   21         Prevent Relapse-Symptom Management I/II/ RN                     47
   22         Hygiene 1:1/ RN                                                 48      Nurse Manager/ NM
   23         Recovery and Relapse Prevention I/II/ SW                        49
   24         Cognitive Applications/ PSY                                     50
   25         AA/ Pt. Ed.                                                     51
   26         Healthstyles/ AT                                                52
                                          Patient may go outside daily, weather permitting: YES
    Members Present:

              Psychiatrist/LPP                            Date/Time              Social Worker                       Date/Time


              Registered Nurse                            Date/Time                  Psychologist                    Date/Time


             Activity Therapist                           Date/Time                     Other                        Date/Time
“This plan was read to me. My signature does not necessarily indicate that I agree with its content.” Any
comments I may have are recorded below:


                            Patient Signature                                 Date/Time
Comments:


Check patient response to plan:
    Participated in plan formulation
    Understands but did not participate in formulation
    Does not appear to understand                                              Plan Coordinator’s Signature / Date/Time
    Has been given a copy of the plan
                                                                      I.D.
SCDMH FORM
MAY 80 (REV MAY 2011) M-203G Pg. 3 of 3
MH-FCC-2

				
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