Comprehensive Master Treatment Plans

1. COMPREHENSIVE (MASTER) TREATMENT PLANS COLORED TO DIFFERENTIATE BETWEENDISCIPLINES To easily visualize that every discipline has added their information to the plan in a timely fashion as well as to note where the information came from.

2. Nursing starts the process the same as before. The only change for nursing is that they are to save their document as a Comprehensive Master Treatment Plan. Example: “David M Comprehensive Master Document”

3. If nursing wants to keep an “original” document that shows what they provided before changes were made, they need to make a duplicate of their document labeled as a nursing document with the date. Example: “David M. Nursing Care Plan 6.20.12”

4. Disciplines other than nursing are to then add their information to the Comprehensive Master Document in the appropriate area of the plan in their disciplines assigned color; Psychology – Green Rehab – Red Social Work – Purple Substance Abuse Counselor – Light Blue PLEASE NOTE THIS IS ONLY FOR COMPREHENSIVE TREATMENT PLANS!

5. If anyone from disciplines other than nursing want a document to show the specific information they added to the client’s plan, that person needs to save their information in a document labeled with their discipline and the date. Example: “David M. Psychology 6.20.12”

6. It is the responsibility of the PCC to combine the information provided by all the disciplines so that the plan is written in language that the client can understand with no abbreviations, no subjective language and with goals and objectives that are realistic and measurable (doesn’t have to include a specific number to be measurable). Example: Client can verbalize XXXXXXX and provide an example that shows he understands/provide a return demonstration.

7. Example: Problem: Psychological Impairment Problem Description: David reportedly has a history of Psychotic symptoms (David was displaying delusional thought disorder and during his spice use thought that there was a chip implanted in his chest. He was found running in the streets naked after smoking spice) and Mood Disorder symptoms (David gets angry easily and acts out on those emotions by destruction of property). He is currently taking an antidepressant and several mood stabilizers for his mood disorder. David also has reported difficulty with sleep related to his symptoms). Goal: * David will reduce impact of psychotic and mood disorder symptoms across areas of functioning (social, recreational, vocational, etc.) over a 60 day period so that these symptoms will not interfere with the patient’s ability to attend and participate in various areas of treatment including class attendance and participation while identifying, developing, and using social acceptable coping skills. Priority:Moderate Objective:* David will report a decrease in the frequency and severity of psychotic and mood disorder symptoms as shown by attending and participating in active treatment classes and psychology classes as recommended. Interventions: Nursing *Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. *Establish a collaborative partnership with David and assist him to identify feelings and thoughts associated with stressful situations and enlist participation in planned activities and therapies. Rehab Therapy *Talk with David about the use of self-soothing and/or self-comforting tools and techniques and encourage David to use them. He will be referred to such classes as Coping Skills, Open Gym, Relaxation Ed., And Coping with stress.

8. THE COLORIZATION OF THE COMPREHENSIVE MASTER TREATMENT PLAN IS TO GO INTO EFFECT JULY 1, 2012

9. You have completed the Comprehensive Tx. Plan training. Print this page, sign your name, enter the date, & send it to Staff Development. Signature: ____________________________ Date: ______________ Printed Name:________________________________________