Vendors and clinicians have employed a variety of approaches in their development of automated treatment plans. Most of the healthcare software developers have integrated treatment planning modules into their client information management systems. The structures are often generic, so they can be used to prepare treatment, education, rehabilitation or other types of individualized service or care plans. Typically, this software is used to establish a hierarchy of problems, goals and objectives. Each patient can have several problems and for each problem there can be multiple goals and related objectives.
The better treatment plan programs have the flexibility to adapt to the terminology and conventions used by an organization. The user should have the capability to change the names of the plan, problem, goal and objective fields. For example a treatment plan may be referred to as an individualized client plan (ICP), or individualized service plan (ISP), individualized habilitation plan (IHP) or individualized education plan (IEP).
The systems typically have the capability to create as many plans for an individual client as required. Each plan should be hierarchical and relational by design. For example, the highest level of the hierarchy is generally the problem or skill area(s) to receive attention during treatment. The next level of the hierarchy incorporates the long-term treatment goals. There may be one or more goals related to each problem. The third level of the treatment plan is the objective. The short-term objectives may be specific interventions, steps, and processes, issues or actions that need to be taken to accomplish a specific goal. Typically, there are multiple objectives associated with each long-term treatment goal. All of the problem, goals and objective codes should be user-definable.
It is also helpful to have a status code associated with each goal and/or objective. This can be used to track how close a client is to achieving his or her objectives and goals. Some systems also allow the therapist to record barriers to completing goals and objectives and strengths or assets. Ideally, the treatment planning function should be integrated with the service notes, client registration, patient abstract, quality assurance, utilization review, scheduling and accounts receivable modules. (Johnson 1996 in Miller).
The following bullets summarize some of the service planning features an organization with multiple types and levels of care might expect:
- Select a service plan pathway/protocol from multiple options with user override: recommend service pathways (service plan including interventions) based on client registration and assessment elements, for example, presenting problems.
- Select a level of service based on severity or level of functioning or referral source determination of these elements
- Record presenting problem in the plan
- Record presenting problem in the plan
- Record and track service goals and status in the plan
- Record and track service objectives and status in the plan
- Dated notes on goals
- Identify and record client and family strengths in the plan
- Record multiple problems
- Record multiple goals and objectives for each problem
- User created glossary or file of standard problems, goals, and objectives
- Goals, objectives can be arranged in hierarchical fashion
- Narrative fields created by the user in an individualized service plan
- Incorporate client data from master client index
- User created categories and data types
- Accommodate Life Domain issues and objectives
- Original service plan and updates and reviews tracked and kept for each component of the plan
- Record interventions, activities, responses associated with service goals and objectives in the plan
- Cost proposed service plan
- Cost delivered service plan
- Incorporate client registration information into the plan
- Incorporate client assessment into the plan
- Incorporate medication and medication regimen, including all changes, into the service plan and service plan update
- Cross reference a client's service plan to progress notes
- Incorporate case management elements: internal and external referrals, consultations, appointments, results, follow up
- Incorporate case management contacts, schedules, responsible parties
- Incorporate discharge/termination criteria
- Incorporate long term plan
- Use, replicate, or link to external service plan formats and templates
- Track deficiencies in or absence of service plan
- Track deficiencies in or absence of service plan
- Integrate multiple service plans by different workers and programs into a single integrated plan of service
- Track due dates for service plans and reviews, re-assessments, outside consultations, referrals, prescriptions and medication regimen review dates.
About The Authors:
Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcs@eos.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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