Creating a Treatment Plan

To create a pre-formatted treatment plan very quickly, follow these steps.

1. Creating a treatment plan

Navigate to a client record and click on the "Notes" tab. Locate the " Select a note type" dropdown menu.  If you are part of a group practice and do not see this option, you may not have been given permission to create notes for this client. You will need the primary clinician to grant you access.

2. Selecting the treatment plan template

Select " Treatment Plan" as the note type and click the Create button.

3. Enter the diagnosis date & time

Use the preformatted area provided to document your diagnosis date and time.

4. Complete the mental status

Use this preformatted area provided to document your client's mental status.  Click "All Within Normal Limits" to set all dropdowns to normal.  You may override any individual status options.

5. Enter presenting problem & treatment plan objective

Use the text area provided to document your client's presenting problems and plan objectives. Completing this section is  required to save your note.

6. Recommend the frequency of treatment

Use this preformatted area provided to document your recommended frequency of moving forward.

7. Primary and additional diagnostic codes

If you plan to print a Superbill or bill the client's insurance carrier for the session, use the dropdown lists provided to search and select the appropriate diagnostic code(s) for your client. You may select a single primary diagnosis code and multiple 'additional' diagnosis codes. 

Good To Know

Diagnosis codes saved in the client's treatment plan will automatically copy into any new treatment plan or therapy note.

8. Digitally signing your treatment plan

Sign the treatment plan by clicking the checkbox declaring the document accurate and complete if no further edits will be required. Click " Save" to save the treatment plan. Unsigned treatment plans will be saved as a draft and can still be edited. Signed treatment plans  can not be edited.

Important Note:

As you are creating/editing a treatment plan, if the page is inactive for at least 60 seconds it will automatically save the document. For this reason, you should never sign the document until after you have verified all the information is accurate.

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