MASTER TREATMENT PLAN Preliminary Plan Internet			HUMBOLDT COUNTY HHS MENTAL HEALTH BRANCH / SEMPERVIRENS
PATIENT NAME Ani P. Bani		ADMIT DATE August 14, 2003			DATE / TIME OF PLAN August 14, 2003 12:25 hrs
DIAGNOSIS from psychiatric evaluation: AXIS I Enter Axis I Diagnosis								AXIS II Enter Diagnosis
AXIS III Medical condition	AXIS IV Letter codes: / describe stressors					AXIS V Current GAF / Highest GAF - Past Year
STRENGTHS From Psychiatric Evaluation [MD]			From Admitting Nursing Assessment [RN]				From Social Service Evaluation, Item 3h [SW]
IDENTIFIABLE DISABILITIES From Admitting Nursing Assessment [RN]								From Social Service Evaluation, Item 3h [SW]
ELOS Expected length of stay from psychiatric evaluation				PROGNOSIS From psychiatric evaluation

Problem / Reason for Hospitalization 1. Show medical necessity: 5150 criteria AMB Enter signs and symptoms or supporting data R/T Enter etiology 2. Show treatment of an approved DSM IV Diagnosis AMB Enter signs and symptoms or supporting data R/T Enter etiology 3. Frequently occurring issues AMB Enter signs and symptoms or supporting data R/T Enter etiology 4. Other problems AMB Enter signs and symptoms or supporting data R/T Enter etiology 5. Other problems AMB Enter signs and symptoms or supporting data R/T Enter etiology 6. Other problems AMB Enter signs and symptoms or supporting data R/T Enter etiology
7. Medical Concerns: a. Enter Med Concern b. Med Concern c. Med Concern d. Med Concern e. Med Concern
Long Term Goals [Discharge Objectives]
1. State goal in objective terms Time Frame 2. State goal in objective terms Time Frame 3. State goal in objective terms Time Frame 4. State goal in objective terms Time Frame 5. State goal in objective terms Time Frame 6. State goal in objective terms Time Frame
Short Term Goals	Target Date	Date Met
1. State goal in objective terms Time Frame	Enter Date
2. State goal in objective terms Time Frame	Enter Date
3. State goal in objective terms Time Frame	Enter Date
4. State goal in objective terms Time Frame	Enter Date
5. State goal in objective terms Time Frame	Enter Date
6. State goal in objective terms Time Frame	Enter Date

Client signature: Date:

MASTER TREATMENT PLAN

PATIENT Ani P. Bani Admit Date: August 14, 2003

			[Name and Title]
	Special procedures for health and safety:
GOALS	Intervention		Name RN
	Medications:	Use this space to note any non-standard orders:	Name MD Name RN
	Medication dose ROUTE FREQUENCY
	Diet: Diet

MASTER TREATMENT PLAN

PATIENT Ani P. Bani Admit Date: August 14, 2003

			[Name and Title]
	Discharge and aftercare plans:		Name LCSW
GOALS	Enter first intervention
	Plans for Continuing Care:		Name LCSW
GOALS	Enter first intervention
	Activities:		Name AT
GOALS	Enter first intervention
MD Signature: Date: Name MD		Social Worker Signature: Date: Name LCSW
Nursing Signature: Date: Name RN		Activity Worker Signature: Date: Name AT
		TREATMENT PLAN REVIEW: