Treatment Plan: What to include and how to format the treatment plan
Your Treatment plan should include the following categories:
Title page
Content of treatment plan (The title of your treatment plan should be on line 1 of page 2).
Brief description of the patient (do not repeat the entire video – BRIEF)
Brief explanation of the presenting psychological symptoms (delusional, jealous, moody, talkative, appears depressed, etc)
Any known medical history, allergies, etc. (If none, state No known allergies, No known medical history).
Your psychiatric diagnosis (supported by the DSM-5 criteria). You can state something like, This patient met criterion 1, 2, 4, 5,A, C, D and 7 from the diagnostic criteria on page 163-164 of the DSM-5 for the diagnosis of ……………
List 2- 3 of the differential diagnosis from the DSM-5, and briefly state why that was chosen as a differential diagnosis, and not as the main diagnosis. (See course materials on Differential Diagnosis) (supported by the DSM-5).
Suicide and/or homicidal risk assessment (Include the 5 components of a suicide risk assessment, do you want to kill yourself, what is your plan, do you have access to that plan, what is your intention, and what is keeping you here (the mitigating factors) See Nursing Suicide Risk Assessment PPT/Kaltura Module 1. Points are deducted if the 5 components of a suicide risk assessment are not written out.
What psychiatric tools or scales you used to help support your diagnosis (include citations).
Medications being ordered (include a citation)
Include name of medication(s) and what the med is used for
Include the route, dosage, frequency
Include black box warnings or what the pt needs to know/foods to avoid, etc.
Non-pharmacological treatments that are being ordered (include citation that supports these). Different diagnoses respond better to different forms of therapy. Some respond to CBT, others to Behavioral Therapy, others to Family Therapy, etc.
Any labs or medical tests that need to be completed to rule out organic causes, for medication monitoring, and so forth (include citation). (include a short line stating why each lab/test is being ordered)
Questions that you would ask to help further solidify your diagnosis (brief list)
Any further directives/resources for the patient (this would include, follow up with primary doctor to monitor HTN or diabetes; directives to follow-up with other members of the comprehensive treatment team; safety plan if you are sending the pt home and they have suicidal or homicidal thoughts; return for medication assessment in x number of weeks, etc. This also includes support group and hotline phone numbers for things like SI and SUD).
References Page – include all citations used in the paper, formatted per APA 7, double spaced and in alphabetical order. References are to include the DSM-5, the course textbook, a drug book of your choice (text or online that has a date), and 1 scholarly journal article reference within the last 5 years, for each of the videos or discussion board prompts being assessed.
[OFF CAMERA] Why did your mom feel you should come in and talk with me today?
[MRS HOUSTON:] She was worried. Mom says I get moody this time of year, every year. I don’t know. Maybe.
[OFF CAMERA:] How are you feeling, when?
[PATIENT:] Not great.
[OFF CAMERA:] What’s not great?
[PATIENT:] Huh. Just down. I’m not doing so well.
[OFF CAMERA:] How’s school?
[PATIENT:] Ok.
[OFF CAMERA:] Just ok?
[PATIENT:] Yeah. I left the program at school. I mean I did and… I’m not doing so well.
[OFF CAMERA:] Are the courses difficult?
[PATIENT:] I understand everything. The teachers are getting to be a bit of a pain. The classes aren’t lustrous (Sighs). I’m in this special business program, where you have to come up with a mock company. I just… I just can’t seem to get it done. That, and all my other projects. I’m already late on two of them.
[OFF CAMERA:] Are you having difficult concentrating?
[PATIENT:] Yeah. I’ll read the headlines in the newspaper and like, five seconds later, I can’t remember what I read. And my classes, when I leave the room, I don’t what we were learning about.
[OFF CAMERA:] Are you having any irregular sleeping or eating patterns?
[PATIENT:] (Sighs) I’ve gained ten pounds. Umm… I’ve slept through five of my classes this month if that answers your question.
[OFF CAMERA:] Have you been able to make any friends?
[PATIENT:] [Shrugs] Yeah. Almost immediately. The people are a lot of fun.
[OFF CAMERA:] What do you do with them?
[PATIENT:] Lately, not so much of anything.
[OFF CAMERA:] What happened?
[PATIENT:] Well, it was a blast when I arrived in August. I made friends almost immediately. We went to concerts and shows, we hung out. And we had a lot of fun.
[OFF CAMERA:] You don’t do any of that now?
[PATIENT:] They kind of annoy me a little bit. I mean nothing I can’t get over. They got really dull. They suddenly started playing board games… and then, things also got busy and with the weather, I don’t want to go outside.
[OFF CAMERA:] Do you particularly dislike the cold weather?
[PATIENT:] It’s not like I have a burning passionate hatred for the cold. I’ve always fretted fall and winter. I’m a summer girl. I like the beach and convertibles. And now…
[OFF CAMERA:] You can’t do any of that.
[PATIENT:] No. In fact you can’t do anything at all.
[OFF CAMERA:] Can you tell me what it is you dislike about this time of the year?
[PATIENT:] It’s dark. And grey. And miserable. The whole city changes, it’s not the same city that I loved in August. September was good. It was beautiful. Sunny, crisp days and, the leaves changing at the end of the month and then it just started getting worse and worse. Even… the snow is grey and black. I didn’t know snow got like that, city snow. I thought snow was white and beautiful. But city snow isn’t like that. Everything is grey. It’s miserable.
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