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.
