A Treatment Plan must be completed prior to completing a Progress Note for a client's first scheduled Therapy Session. This is because the Diagnosis, Objectives, and Frequency of Treatment are initially recorded on a client's Treatment Plan and pull forward into subsequent Progress Notes for the client.
If you do not want to write a Treatment Plan before the first appointment with a client, you can schedule a Consultation or Intake and subsequently write either a Consultation or Intake Note.
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 Create a Note.
Note Header
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
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 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 choose the estimated time for the completion of treatment from the dropdown.
Discharge Criteria & Additional Information
Discharge Criteria/Planning can be used to identify what differences are expected when treatment is completed, such as proficiency with a new skill, additional supports, or changed behaviors. Additional Information can be used for other relevant information for treatment such as barriers to treatment, crisis, or safety plans.
Objectives
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 select the estimated time for the completion of the objective. Each Objective is pulled forward into subsequent Progress Notes for the client so that progress can be regularly documented.
Frequency of Treatment
Select from the dropdown or type in how often you plan to see the client moving forward in the Prescribed Frequency of Treatment field. This information is pulled forward into subsequent 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.
Sign and Save
Once you have completed the 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.
Share With Client
Signed Treatment Plans can be shared with clients so that the client may review and/or sign the treatment plan online.
To Share a Treatment Plan:
- Click Patients > Patient name > Documents tab
- Click on the name of the Treatment Plan.
- Click the Share on Portal button at the bottom of the page.
- Under Documents Included in Request, E-sign is selected by default for the Treatment Plan. If you do not need your client's signature, deselect this option.
- Add other documents to share, if necessary. If needed, enter Instructions.
- Click the Send Document Request button.
For more information on document sharing, read Share Documents With Clients on TherapyPortal.