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Treatment Plan

Overview of Process

“The treatment plan is the road map that a patient will follow on his or her journey through treatment….Treatment planning begins as soon as the initial assessments are completed…[and] is a never-ending stream of therapeutic plans and interventions, (Perkinson, et al, 2009, p. 75).” Each agency requires will require atreatment plan for clients and have a specified deadline for completion. It is eventually included as a part of the client’s permanent record and becomes a map for the services provided.

How to Define Problems.

Ingram (2012) defines clinical case formulation as “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (p. 3).” The first step to defining the problem is gathering data from the client, significant others, clinical records, and one’s own clinical judgment. This information can allow us to develop a problem list, which we can utilzie to develop diagnoses that can indicate potential treatment targets (Ingram. 2012).

BASIC SID….

Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43). Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).

Standards for Defining Problems

  1. Problems are define solvable goals for treatment.
  2. Problem titles define to the client’s real-world problems & current functioning.
  3. Problems are written clearly and tailored to the client’s specific situation.
  4. Problems do not pertain to theoretical concepts & clinical hypothesis.
  5. Problem’s reflect the client’s value system & not therapist’s.
  6. The problem list is complete & comprehensive

How to Define goals

Every problem listed requires a treatment goal to resolve the issue. Success of therapy is measured in terms of evidence of progress toward the goal. They also provide a guideline for treatment planning and criteria for when to terminate therapy. There are four standards for defining goals:

  1. There should be a logical connection between the outcome goal and the problem title.
  2. The goals should be theoretically neutral.
  3. The goals should be realistic, measurable, and attainable.

Standards for Writing a Treatment Plan

  1. Focused on resolving problems and achieving goals.
  2. The plan is logically related to the clinical hypotheses & data gathered.
  3. The plan pertains to knowledge of clinical research.
  4. It is strategically clear problem -> evidence -> goal -> objective -> intervention.
  5. The plan pertains to the client’s specific situation
  6. The plan is appropriate given situational constraints, (insurance, treatment setting, etc).
  7. The plan addresses legal & ethical issues.
  8. The plan utilizes referrals and community resources.

Essential Elements of a Treatment Plan

The Problem List

img_3082The problem list reflects problems that need to be addressed during the treatment process. “The problems must be specific, [and provide] a brief clinical statement of a condition of the patient that needs treatment, (Perkinson, 2009, p. 76).” Since the problems are abstract concepts by themselves, treatment plans list evidence of signs and symptoms for every problem listed.

Developing Goals

“Once you have generated a problem list, you need to ask yourself what the patient needs to do to restore normal functioning, (Perkinson, 2009, p. 77).”

Difference between goals and objectives

  1. GOALS define what you hope to achieve in therapy with the client.
  2. OBJECTIVE: Define what the client will do to achieve this outcome
  3. GOAL = TREATMENT
  4. OBJECTIVES = STRATEGY

How to write them…

img_3083“A goal is a brief clinical statement of the condition you expect to change in the client…You must state state what you intend to accomplish in general terms, and then specify the condition of the patient that will result from treatment. All goals will label a set of behaviors that you want to elicity in the patient, Goals should be more than the elimination of pathology. They should be directed toward learning…(Perkinson, 2009, p. 77).”

Treatment Objectives

img_0429After listing problems and goals, you list objectives.  Objectives are list specific skills that the patient will exercise in order to achieve a goal.  “It is a concrete behavior that you can see, hear, smeel, taste or feel…[and] must be stated clearly so that anyone would know when he or she saw it.

Defining Interventions

Interventions follow objectives.  “Interventions are what you do to help the patient complete the objective…they are also measurable and objectives…There should be at least one intervention for every objective.  The person responsible for the intervention should be listed.

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Avoiding Errors

For successful case formulation to occur, it is essential that the resulting treatment plan matches the client’s specific needs (Ingram, 2012). Our textbook also lists three common errors associated with matching a treatment plan with the client’s specific needs.   The first of these errors involves developing a case formulation without adequate data to support underlying hypotheses (Ingram, 2012). In order to avoid this error, I believe it will help to complete the “three-column worksheet” (Ingram, 2012, p88), described in our text. Another useful preventative for this mistake is to make sure your data is complete. The second error mentioned in our textbook involves the presence of data that contradicts a case hypothesis (Ingram, 2012). As Ingram, (2012), mentions it is essential that a therapist enter the data-gathering process without a predefined orientation (p89).   I would surmise, that doing so would color a therapist’s understanding of the client’s situation. The final case formulation error mentioned in our textbook involves failing to address a key issue in the client’s case.   If a wealth of data exists in support of a specific case hypothesis, it would be a disservice on the part of our client’s to overlook this issue.   One step therapists can take to prevent this might involve carefully reviewing information from the database after the initial interview process. A second step a therapist can take, might involve a consultation with a co-worker or supervisor.

Sample Treatment Plan

Attached is a copy of a treatment plan I created for a class.  It doesn’t refer to an actual client and is purely a hypothetical and acdemic exercise.  Keep in mind, it is my first attempt… 🙂

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References

Ingram, B.L. (2012). Clinical Case Foundations: Matching the Integrate Treatment Plan to the Client. (2nd. Ed.). Hoboken, NJ: Wiley.
Perkinson, R. R., & Jongsma Jr, A. E. (2009). The addiction treatment planner (Vol. 254). John Wiley & Sons. Retrieved from: http://www.sagepub.com/sites/default/files/upm-binaries/18970_Chapter_5.pdf

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SOAP NOTES

Overview

Progress notes provide an “organized method of planning, giving, evaluating, and recording rendered client services. A viable method of record keeping is SOAP noting.  SOAP is an acronym for subjective (S), objective (O), assessment (A), Plan (P), with each letter representing one of the sections of the case notes, (Cameron, et al, 2002, p. 286).”  Most agencies also have a deadline regarding when documents must be completed and entered into the client’s file.  Progress notes are usually required within 24-48 hours after as session.  Widely utilized in medical settings, it is also common within the counseling field.

Problem Solving Process

A textbook of mine describes the process of clinical case formulation defining it as: “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (Ingram, 2012, p. 3).”  Essentially, this process involves four basic steps: (1) identifying the problem, (2) seeing explanations for them, (3) plan implementations, (4), defining goals, (Ingram, 2012).

  1. GATHERING DATA:  includes subjective and objective data, it is free of assumption, interpretation and/or diagnosis (Ingram, 2012).
  2. DEFINING THE PROBLEM:  stated in simple terms, the problem should be defined as solvable targets for treatment.  It should be comprehensive and complete, reflecting client’s values & not the counselors (Ingram, 2012).
  3. GOALS & OUTCOMES:  There should be a logical relationship between the problems and goals.  They should be realistic, attainable, and testable. Ingram, (2012) describes core clinical hypotheses as useful in these cases and defines them as follows: “a single explanatory idea that helps to structure data about a given client in a way that leads to be better understanding, decision making, and treatment choice, (p. 11).”  
  4. TREATMENT PLAN: includes a description of interventions used to address the client’s problems.  Includes process goals and outcome goals.

Components of the SOAP NOTE

Subjective vs. Objective

Ingram (2012), provides a clear differentiation between subjective and objective data in the folloiwng statement: “What the client ells you goes in [SUBJECTIVE DATA}…how the client tells it goes in [OBJECTIVE DATA], (p. 83).” In other words, the subjective section provides the client’s story in their own words.  The objective data contains observations on how the client tells the story.

(S) Subjective

The purpose of subjective data is to provide a place where the client’ own story can be told.  For this reason, it contains information from the client and the client’s family.  “Without losing accuracy, the entry should be as brief and concise as possible; the client’s perceptions of the problem(s) should be immediately clear to an outside reader, (Cameron, 2002, p. 287).”  Quotations should be kept to a minimum, however important statements pertaining to thoughts such as SI and/or HI, for example should be included.

What client tells you.
What significant others tell you.

(O) Objective

The objective data includes clinical observations, medical records, and the therapist’s impressions.  It excludes case formulation and information pertaining to either the client or family members’ verbal reports.  Objective information should be factual, “written in quantifiable terms – that which can be seen heard smelled, counted, or measured.”  Objective information included can come either from outsider records or the counselor’s observations.  Include information which is precise and descriptive, (i.e. “As evidenced by”).  Words with negative judgments that are open to interpretation should be excluded.   During my practicum class, the instructor required us to include the following: (1) general, (2) speech, (30 psychomotor, (4) mood, (5) affect, (6) thought, (7) insight & judgment, (8) impulse control.

factual information
counselor observations
Information from outside records

(A) Assessment

This section provides an overview of the client’s clinical judgment.  It draws on information from the subjective and objective sections.  It often lists client’s symptoms, diagnoses, and clinical impression.  Cameron, et al, (2002) notes: “the assessment portion of the SOAP notes is the most likely section to be read by others, such as outside reviewers auditing records, (p. 289).”

Summary of counselor’s clinical judgment.
Synthesis of information from subjective & objective sections.

(P) Plan.

Consisting of the plan and prognosis, information here can include a list of future interventions, appointments, treatment progress, and/or psychoeducation.  “the prognosis is a forecast of the probable gains to be made by the client given the diagnosis, the client’s personal resources, and motivation to change, (Cameron, et al, 2002, p. 289).”

Plans for therapy
Overview of treatment plan
Description of client’s prognosis.

An Example of a SOAP NOTE…

This example comes from my practicum class in which I recorded a series of sessions with an individual who was “playing the part” of a character.  Therefore, it does not pertain to an actual client, and is a byproduct of a hypothetical exercise.    Additionally, since it is important to keep in mind, this was my “first” effort at every doing a progress note, (therefore its far from perfect)… 🙂

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POMR – An Alternative to SOAP

Cameron, et al, (2002) also discuss an alternative to the SOAP Format. POMR is an acronym which stands for “Problem-Oriented Medical Record.  It begins with a review of the clinical assessment and continues with a list of problems derived from this history.  It concludes with a treatment plan and progress note.  To read more about this document click here.  It is utilized commonly within the health care field it contains four components:

  1. Data Base – History

  2. Physical Exam and Laboratory Data

  3. Complete Problem List

  4. Initial Plans

  5. Daily Progress Note

  6. Final Progress Note or Discharge Summary

Resources & References

Template of Information to Include in SOAP Note…

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development: JCD, 80(3), 286-291
Ingram, B.L. (2012). Clinical Case Foundations: Matching the Integrate Treatment Plan to the Client. (2nd. Ed.). Hoboken, NJ: Wiley.

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