How To: Complete a Psychotherapy Treatment Plan

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The Diagnosis, Objectives, and Frequency of Treatment are initially recorded on a client's Psychotherapy Treatment Plan and pull forward into subsequent Psychotherapy Progress Notes for the client. Because of this, a Treatment Plan must be completed prior to completing a Progress Note for a client's first scheduled Therapy Session.

If you do not want to write a Treatment Plan before the first appointment with a client, you can schedule a Consultation or Psychotherapy Intake and subsequently write either a Consultation or Psychotherapy Intake Note. Note: An Intake is not needed if you complete a Treatment Plan.

TherapyNotes will prompt you to create a Treatment Plan after you create an Intake Note for a client and will generate a To-Do list item as a reminder to create a Treatment Plan for the client. To learn more about creating notes and note writing tools in TherapyNotes, read How To: Create a Note.

Role Required: Clinician, Intern, or Clinical Administrator

Note Header

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The note header automatically fills in information for the clinician, client, and date and time the note was created. To edit information in the note header such as the Note Title or Date & Time, click anywhere on the note header or click Edit in the upper right corner.

Diagnosis

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The Diagnosis fields feature searchable DSM-5 diagnoses, allowing you to easily add and edit diagnoses. If an Intake Note was completed prior to the creation of the Treatment Plan, the DSM-5 diagnoses, descriptions, and justification will automatically pull forward into the Treatment Plan. Diagnostic information will also pull forward into subsequent Psychotherapy Progress Notes and Psychological Evaluations.

Presenting Problem

If an Intake Note was completed prior to the creation of the Treatment Plan, the Presenting Problem will automatically pull forward into the Treatment Plan. Otherwise, enter the reason for treatment.

Treatment Goals

Enter the broad goals for the client's treatment and the estimated time for the completion of treatment.

Objectives

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Enter each of the steps you intend to take to work towards the Treatment Goals.

Multiple objectives may be entered by clicking Add New Objective. For each Objective, enter the Treatment Strategy / Interventions and the estimated time for the completion of the objective. Each Objective is pulled forward into subsequent Psychotherapy Progress Notes for the client so that progress can be regularly documented.

Frequency of Treatment

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Enter how often you plan to see the client moving forward in the Prescribed Frequency of Treatment field. This information is pulled forward into subsequent Psychotherapy Progress Notes for the client.

Before signing the Treatment Plan, select I declare that these services are medically necessary and appropriate to the recipient's diagnosis and needs to continue with treatment.

Sign and Save

Note: In order to save a Psychotherapy Treatment Plan, you must enter the Diagnosis, Presenting Problem, and Prescribed Frequency of Treatment. All other fields are optional. 

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Once you have completed the Psychotherapy Treatment Plan for your client, select the Sign this Form checkbox to electronically sign the note and click the Create Note button.

To save an unfinished Treatment Plan, leave Sign this Form unchecked and click the Save Draft button. You may access your draft later from your To-Do list or click Patients > Patient Name > Documents tab.

Have more questions? Submit a request

Comments

  • Avatar
    Fariba Ghorbani

    how can I strat using this program?

  • Avatar
    Sean Behan

    Hi Fariba,

    One of our support staff will reach out to you to help you get started with our software. Please let us know if you have any other questions. Thank you.

  • Avatar
    Tammy Cooper

    Is it possible to create several treatment plans (goals, objectives, and interventions) to have stored and applied to clients as needed?

  • Avatar
    Rachael

    Tammy,

    You can create several treatment plans to one patient, however the last treatment plan that is created will transfer onto each progress note. If you have multiple clinicians seeing one patient and each user creates a treatment plan, then those plans that those users create will transfer onto the notes they create. If this does not answer your questions please contact support so we can fully answer your question.

  • Avatar
    James Bruce

    How do you updat a treatment plan when prompted by the "to do" list. Jim

  • Avatar
    Rachael

    James,

    To update a Treatment Plan from a To-Do List prompt, click the link that says 'Create New Treatments Plan...' and complete the Treatment plan template. You can also update an existing treatment plan by Clicking the patients name from the To-Do List > Documents tab > Select the original Treatment Plan > 'Edit' > Make any necessary changes > Sign and Save. If you have further questions, please contact our Support Team at 215-658-4550. Thank you.

  • Avatar
    Amelia Mueller

    does this program require clients to sign tx plans? where should they sign

  • Avatar
    Rachael

    Amelia,

    Clients are not currently required to sign treatment plans within TherapyNotes. This is an option we will be adding in a future update. If you have further questions, please contact our Support Team at 215-658-4550, or by email at Support@TherapyNotes.com. Thank you.

  • Avatar
    Ryan Farmer

    Can note (or report) templates be modified? We would very much like our notes to resemble our clinic's traditional note rather than the pre-specified setup.

  • Avatar
    Rachael

    Ryan,

    There are certain aspects of our note templates that can be customized such as the interventions list, the title of the note, and the diagnosis codes. However, the fields and sections in our note templates cannot be added to, removed or customized. We have done many years of research on our note templates that are based on the SOAP note template. TherapyNotes also includes the Consultation Note, which is a blank text field that can be used for multiple purposes. For example, you can copy and paste a note from Microsoft Word into the Consultation Note. If you have a specific example of note template you would like to use, please send a blank copy for us to review. If you have any questions, please contact our Support Team at 215-658-4550, or by email at Support@TherapyNotes.com. Thank you.

  • Avatar
    Cristina Morue

    When will an electronic signature be added to the treatment plan for client's to sign?

  • Avatar
    Rachael

    Cristina,

    This is a feature we will be adding as part of an update to our Client Portal. We are expecting to release this update by the end of the year. If you have any questions, please contact our Support Team at 215-658-4550 or by email at Support@TherapyNotes.com. Thank you.