PRELIMINARY TREATMENT PLAN

Master Plan

Internet

HUMBOLDT COUNTY HHS MENTAL HEALTH BRANCH / SEMPERVIRENS

PATIENT NAME Ram   Singh

ADMIT DATE April 28, 2003

DATE / TIME OF PLAN April 28, 2003 03:25 hrs

PRELIMINARY DIAGNOSIS from admission orders:   Enter Provisional Axis I Diagnosis

   

   

   

       

STRENGTHS ____________________ [MD]

From Admitting Nursing Assessment [RN]

____________________ [SW]

IDENTIFIABLE DISABILITIES From Admitting Nursing Assessment [RN]

____________________ [SW]

ELOS ____________________

PROGNOSIS ____________________

 

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:

 

PRELIMINARY TREATMENT PLAN

PATIENT Ram   Singh                                                                                                                 Admit Date: April 28, 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

 

 

 

PRELIMINARY TREATMENT PLAN

PATIENT Ram   Singh                                                                                                                 Admit Date: April 28, 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: