treatment record review educational materials · treatment record review educational materials ......

This document was developed by Magellan Health Services Southeast Care Management Center

Treatment Record Review Educational Materials

(The enclosed templates are provided by Magellan Health Services Southeast Care Management Center as examples only. Modifications may be needed to comply with your respective State Laws).

The enclosed materials are intended to assist with improved documentation, as well as:

• Improve collaboration between members and providers • Improve communication between providers (i.e. behavioral health practitioners and primary

care providers as well as other providers involved in members’ care) • Improve members’ understanding of medication and the importance of proper medication

adherence • Empower the member to take an increased role and realize the importance of personal

accountability in the ultimate success of their treatment.


Treatment Record Review Educational Materials Table of Contents

I. Member Rights and Responsibility Statement……………………2 pages

English and Spanish versions • To be obtained on initial visit • To be posted in the office and a signed member copy should included in the

treatment record

II. Authorization to Use or Disclose Protected Health Information …………...…………………………………………….……………. 1 pages

• To be obtained on initial visit and as appropriate, thereafter

III. Clinician Communication Form ………………………………… 1 page • Contact with PCP should be made following the initial evaluation and at

pertinent times during treatment (safety issues, medication changes, treatment plan changes, hospitalization and termination)

IV. Informed Consent for Treatment Template…………………….... 1 page

• To be obtained on initial visit

V. Medication Consent Template……………………...…………….. 1 page • To be obtained if medications are prescribed

. VI. Initial Evaluation Template………………………...….………….. 5 pages

• To be completed on initial visit

VII. Progress Notes Template………………………….……………….2 pages • To be completed during follow-up visits

VIII. Treatment Plan Template/Examples…………….……………......3 pages

• To be completed after initial evaluation

IX. Substance Abuse Assessment…………….…………..…....………..1 page

X. Depression Screening……………………………………..…….…...1 page

XI. Suicide Risk Assessment……………………………………....……1 page

XII. Second Generation Antipsyhchotics…………………...…………...2 pages • Tip Sheet • Metobolic Syndrome Monitoring Log

XIII. Discharge Summary Template………….…………….……………..1 page

• To be completed within 60 days of last visit

Members’ Rights and Responsibilities Statement 2009 Approved June 24, 2009

MAGELLAN HEALTH SERVICES MEMBERS’ RIGHTS AND RESPONSIBILITIES STATEMENT

Statement of Members’ Rights

Members have the right to:

Be treated with dignity and respect.

Be treated fairly, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.

Have their treatment and other member information kept confidential. Only where permitted by law may records be released without the member’s permission.

Easily access care in a timely fashion.

Know about their treatment choices. This is regardless of cost or coverage by their benefit plan.

Share in developing their plan of care.

Receive information in a language they can understand.

Receive a clear explanation of their condition and treatment options.

Receive information about Magellan, its providers, programs, services and role in the treatment process.

Receive information about clinical guidelines used in providing and managing their care.

Ask their provider about their work history and training.

Give input on the Members’ Rights and Responsibilities policy.

Know about advocacy and community groups and prevention services.

If asked, Magellan will act on the member’s behalf as an advocate.*

Freely file a complaint or appeal and to learn how to do so.

Know of their rights and responsibilities in the treatment process.

Request certain preferences in a provider.

Have provider decisions about their care made on the basis of treatment needs.

Receive information about Magellan’s staff qualifications and any organization Magellan has contracted with to provide services.*

Decline participation or withdraw from programs and services.*

Know which staff members are responsible for managing their services and from whom to request a change in services.*

Statement of Members’ Responsibilities

Members have the responsibility to:

Treat those giving them care with dignity and respect.

Give providers and Magellan information that they need. This is so providers can deliver quality care and Magellan can deliver appropriate services.

Ask questions about their care. This is to help them understand their care.

Follow the treatment plan. The plan of care is to be agreed upon by the member and provider.

Follow the agreed upon medication plan.

Tell their provider and primary care physician about medication changes, including medications given to them by others.

Keep their appointments. Members should call their provider(s) as soon they know they need to cancel visits.

Let their provider know when the treatment plan is not working for them.

Let their provider know about problems with paying fees.

Report abuse and fraud.

Openly report concerns about the quality of care they receive.

Let Magellan and their provider know if they decide to withdraw from the program.*

* This standard is required for our Condition Care Management (CCM) products.

My signature below shows that I have been informed of my rights and responsibilities, and that I understand this information.

_______________________________________________ Member Signature Date

The signature below shows that I have explained this statement to the patient. I have offered the member a copy of this form. _______________________________________________ Provider Signature Date

Declaración de Derechos y Responsabilidades de las Personas Inscriptas en Medicaid 20 de abril, 2009

MAGELLAN HEALTH SERVICES

DECLARACIÓN DE DERECHOS Y RESPONSABILIDADES DE LAS PERSONAS INSCRIPTAS EN MEDICAID

Declaración de los derechos de los inscriptos

Toda persona inscripta tiene el derecho a:

A. Ser tratada con respeto y con consideración de su dignidad y privacidad.

B. Ser tratada justamente, sin importar su raza, religión, sexo, origen étnico, discapacidad o medio de pago.

C. Que la información sobre su tratamiento y otra información de miembro se mantenga privada y confidencial. Solo cuando lo permita la ley se podrán revelar los registros sin el permiso de la persona inscripta en el plan.

D. El fácil acceso en el tiempo adecuado.

E. Recibir información sobre las opciones y alternativas de tratamiento disponibles, presentada en la manera adecuada, según la condición y la habilidad para entender de la persona inscripta.

F. Ser parte del desarrollo de su plan de atención médica.

G. Recibir servicios de interpretación gratuitamente, incluido el derecho a recibir información en un idioma que pueda entender. La información está disponible en formatos alternados cuando se solicita.

H. Recibir información sobre Magellan, su personal médico, programas, servicios y papel que cumplen dentro del proceso de tratamiento.

I. Recibir información sobre las pautas clínicas utilizadas para proporcionar y administrar su cuidado médico.

J. No ser restringida ni recluida para hacerle hacer algo que la persona no quiere hacer.

K. Dar su opinión sobre la política de Derechos y responsabilidades de Magellan.

L. Saber sobre los grupos comunitarios y que interceden por el miembro, además de los servicios preventivos. Si la persona lo requiriera, Magellan intercederá a favor del miembro.*

M. Solicitar ciertas preferencias respecto al proveedor.

N. Solicitar que las decisiones del proveedor sobre su tratamiento se hagan en base a las necesidades de tratamiento.

O. Que se le presten los servicios médicos según las leyes estatales y federales sujetas a los derechos de las personas inscriptas.

P. Participar en decisiones respecto a su atención médica, incluido el derecho de recibir una segunda opinión médica y el derecho a rechazar el tratamiento.

Q. Ser libre de cualquier forma de restricción o reclusión utilizada como medio de coerción, disciplina, conveniencia o represalia, de acuerdo a lo especificado en las normas federales sobre el uso de restricciones y reclusiones.

R. Levantar una queja/agravio sobre Magellan, un proveedor o el tratamiento recibido.

S. Presentar una apelación sobre una acción o decisión de Magellan y solicitar una Audiencia imparcial a nivel estatal, si no estuviera satisfecha con el resultado de la apelación.

T. Solicitar y recibir una copia de sus registros médicos y solicitar que se corrijan o enmienden, según lo especificado en 45 CFR, parte 164.

U. Ejercitar sus derechos y que el ejercicio de esos derechos no afecte adversamente la manera en que Magellan y sus proveedores traten a la persona.

V. Recibir información escrita sobre directivas avanzadas y sus derechos bajo la ley estatal.

W. Recibir información sobre las calificaciones del personal de Magellan y cualquier organización con la que Magellan haya contratado para proporcionar servicios.*

X. Renunciar a su participación o abandonar los programas y servicios.*

Y. Saber cuáles miembros del personal son responsables por administrar sus servicios y de quién requerir un cambio en servicios.*

Declaración de las responsabilidades de los inscriptos

Las personas inscriptas tienen las siguientes responsabilidades:

A. Tratar a aquellos de los que reciben atención médica con dignidad y respeto.

B. Dar a los proveedores y a Magellan la información que necesitan. Esto se hace para que los proveedores puedan ofrecerle un servicio de calidad y para que Magellan pueda brindar el servicio adecuado.

C. Hacer preguntas a los proveedores sobre su caso. Esto es para ayudarlos a entender su tratamiento.

D. Seguir el plan de tratamiento. La persona inscripta y el proveedor se pondrán de acuerdo en cuanto al plan de atención médica.

E. Seguir el plan médico al que se comprometieron.

F. Indicar a sus proveedores y al médico de cabecera sobre cambios de medicamentos, incluidos los medicamentos que otros les recetaran.

G. Mantener sus citas. Los inscriptos deberán llamar a sus proveedores tan pronto como sepan que deben cancelar sus visitas.

H. Hacer saber al proveedor cuando el plan de tratamiento no es efectivo para ellos.

I. Hacer saber al proveedor sobre los problemas de pago de cualquier copago o deducible requerido.

J. Comunicar el abuso o fraude. Para ello, se puede comunicar con la línea gratuita de Cumplimiento con las normas corporativas (Corporate Compliance) las 24 horas del día, 7 días a la semana, mantenida por un proveedor externo. Las personas que llaman pueden permanecer anónimas. Todas las llamadas se investigarán y se mantendrán confidenciales. Comunique el fraude, el tiempo desperdiciado y el abuso mediante uno de los siguientes métodos: ♦ Línea gratuita de la Unidad de investigaciones especiales: (800) 755-

0850 ♦ Correo electrónico de la Unidad de investigaciones especiales:

[email protected] ♦ Línea gratuita de Cumplimiento con las normas corporativas: (800)

915-2108 ♦ Correo electrónico de Cumplimiento con las normas corporativas:

[email protected]

K. Comunicar abiertamente sus preocupaciones sobre la calidad del servicio.

L. Comunicar por escrito a Magellan y al proveedor del tratamiento si deciden anular su inscripción en el programa*.

* Se requiere este estándar para nuestros productos Condition Care Management (CCM).

Mi firma a continuación indica que se me ha informado de mis derechos y responsabilidades, y que entiendo esta información.

_______________________________________________ Firma del miembro inscripto Fecha La firma a continuación indica que he explicado esta declaración al paciente. He ofrecido al miembro una copia de esta forma. _______________________________________________ Firma del proveedor Fecha

mailto:[email protected]

mailto:[email protected]

Last Updated: 01/10/06

Authorization to Disclose Protected Health Information to Primary Care Physician Communication between your behavioral health provider(s) and your primary care physician (PCP) is important to make sure all care is complete, comprehensive, and well-coordinated. This form allows your behavioral health provider to share valuable information with your PCP. No information will be released without your signed authorization. Once completed and signed, please give this form to your behavioral health provider.

Section 1. The Patient Last Name

First Name

Middle Initial

Subscriber Number From ID Card

Insurance Company Name

Date of Birth (MM/DD/YYYY)

Phone Number

I hereby authorize the disclosure of protected health information about the individual named above. I am: the individual named above (complete Section 8 below to sign this form) a personal representative because the patient is a minor, incapacitated, or deceased (complete Section 9 below)

Section 2. Who Will Be Disclosing Information About the Individual? The following behavioral health provider may disclose the information:

Name (a person, or an organization if you are naming a facility)

Phone Number (if known)

Section 3. Who Will Be Receiving Information About the Individual? The information may be disclosed to the following primary care physician:

Name (a person, or an organization if you are naming a practice)

Phone Number (if known)

Street Address (if known)

City, State and Zip Code (if known)

Section 4. What Information About the Individual Will Be Disclosed? Any applicable behavioral health and/or substance abuse information, including diagnosis, treatment plan, prognosis, and medication(s) if necessary.

Section 5. The Purpose of the Disclosure To release behavioral health evaluation and/or treatment information to the PCP to ensure quality and coordination of care.

Section 6. The Expiration Date or Event

This authorization shall expire 1 year from the date of signature below unless revoked prior to that date.

Section 7. Important Rights and Other Required Statements You Should Know You can revoke this authorization at any time by writing to the behavioral health provider named above. If you revoke this

authorization, it will not apply to information that has already been used or disclosed. The information disclosed based on this authorization may be redisclosed by the recipient and may no longer be protected by federal or

state privacy laws. Not all persons or entities have to follow these laws. You do not need to sign this form in order to obtain enrollment, eligibility, payment, or treatment for services. This authorization is completely voluntary, and you do not have to agree to authorize any use or disclosure. You have a right to a copy of this authorization once you have signed it. Please keep a copy for your records, or you may ask for a copy

at any time by contacting your behavioral health provider named above.

Section 8. Signature of the Individual

Signature_________________________________________ Date (required) _________________________________

Section 9. Signature of Personal Representative (if applicable)

Signature_________________________________________ Date (required) _________________________________ Relationship to the individual (required): __________________________________________________________________

Clinician Communication Form Patient Name: _____________________________ Patient Date of Birth: ____________ Clinician Name: _______________________________________________________ Clinician Address: _______________________________________________________ _______________________________________________________ Clinician Phone/Fax: ____________________________ Dear Colleague: I saw the above-named patient, who gave an authorization to release the following information, on _____________ for_________________________ (Date) (Reason/Diagnosis) Brief Summary (if indicated): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Current Treatment (interventions by sending practitioner): Psychotherapy Patient Refused Medication Medication(s) Prescribed: ________________________________________________ _______________________________________________________________________________________________________________________________________________ Treatment terminated (date/reason): __________________________________________ _______________________________________________________________________ Treatment Recommendations (interventions requested of receiving practitioner): _______________________________________________________________________ _______________________________________________________________________ Lab Tests: CBC Thyroid Studies Chem Profile EKG Lipid Profile Serum drug level (specify drug)______________ Other: _______________________________________________ Diagnostic Tests: _________________________________________________________ The patient has has not received a copy of this form. If you have any questions or would like additional information, please contact me. Thank you. Clinician Signature: __________________________ Date Sent/Faxed: _____________ Clinician Phone #: _________________________ Revised 7/11


Informed Consent for Treatment Template

Patient’s Name/ID#________________________ Date: __________________ I, ___________________________ (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by, ___________________(name of provider), a behavioral health provider. I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to perform within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the behavioral health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of the above named individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. Signature:________________________ Date:_____________________ Relationship to Patient (if applicable):____________________________


Medication Consent Form Template

Patient’s Name/ID#:_____________________________ Date: _________________ Types of Medication (s): __ Antipsychotic __ Antidepressant __ Antimanic __ Antianxiety __ Stimulants __ Anticonvulsants __ Other List of Medications: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ __________________________________ (name of provider prescribing medications) has educated me regarding the medication (s) prescribed to ____________________________ me/my child/or a person for whom I am the legal guardian (circle one). I consent to the administration of this medication. I have been educated regarding the possible side effects of this medication, possible drug and/or food interactions that may occur while taking this medication, and the possible effects of this medication if the person taking it becomes pregnant. I have also been informed of the reason or purpose for which this medication was prescribed. Patient’s Name: ______________________________________________________________ Patient/Legal Guardian Signature: ________________________________________________ Provider’s Signature: __________________________________________________________ Reminder to Patients/Health Care Providers:

• It is recommended that women who are or may be pregnant, or are breastfeeding discuss this with their doctor before taking any medications.

• It is recommended that patients be educated on reporting all side effects they experience, including but not limited to which side effects to report immediately to a health care provider.

• It is recommended that any provider prescribing medications obtain a thorough patient history that should include (but may not be limited to):

1. All medications, including prescribed and over-the-counter medications the patient is currently taking or has taken in the past.

2. Any food and drug allergies in the patient’s hx. 3. Any medical conditions in the patient’s hx.

• It is recommended that DEA scheduled drugs be avoided in treatment of members with a history of substance abuse/dependency.

Initial Evaluation Template

This document was developed by Magellan Health Services Southeast Care Management Center rev: 06/11

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Demographic Information (Please complete all questions on this form)

Date: ________________ Name:________________________________________________________________________ Address:______________________________________________________________________ Phone (Home):______________________ Phone (Work): __________________________ Date of Birth: _______________________ Social Security #: Guardianship (for children and adults when applicable): ________________________________ Marital Status (check one) Race (optional) [] Never Married [] Divorced [] White [] Native American [] Married [] Separated [] African-American [] Asian [] Widowed [] Cohabiting [] Hispanic [] Other Are you adopted: [] Have you ever spent time in foster care: [] If yes to either, what is your foster care/adoption story? ____________________________________________________________________________________ Gender: [] Male [] Female Age: ___________ Family Members: Name Age Sex Relationship ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Employer: ____________________________Occupation: School (for children, and adults when applicable): Referral Source: __________________________________________________________ Insurance Information: Insurance Company/HMO: _______________________________Phone: ____________ Member ID# _______________________ Managed Care Company_______________ Claims Address: _______________________________________Phone: ____________ Emergency Information: Name of Emergency Contact: ___________________________ Phone: ____________ Relationship to Patient:____________________________________________________ Advance Directives: I have an Advanced Directive/Instruction for Mental Health Treatment. ____YES ____ NO



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Patient’s Name/ID: _______________________________________________________ Source of Information: (patient, family, other):_______________________________ Presenting Problem (include onset, duration, intensity): ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Precipitating Event (why treatment now?):___________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Mental Status (circle appropriate items): Appearance: Appropriate Inappropriate Disheveled Unclean Bizarre Affect: Appropriate Inappropriate (describe):__________________ (sad, angry, anxious, superficial, restricted, labile, flat) Orientation: Oriented Disoriented (to person, place, time, date, day, situation) Mood: Normal Other________ (euthymic, depressed, irritable, angry) Thought Content: Appropriate Inappropriate Thought Process: Logical Tangential Illogical Speech: Normal Slurred Slow Pressured Loud Motor: Normal Excessive Slow Other________ Intellect: Average Above Below Insight: Present Partially Present Absent Judgment: Normal Impaired Impulse Control: Normal Impaired Memory: Normal Impaired Immediate Recent Remote Concentration: Normal Impaired Attention: Normal Impaired Behavior: Appropriate Inappropriate (anxious, agitated, guarded, hostile, drowsy,

cooperative, hyperactive, psychomotor retarded) Thought Disorder: No Problem

Delusions Grandiosity Paranoia Ideas of reference Tangential Loose associations Perseveration Confusion Thought blocking Obsessions Flight of ideas Hallucinations Phobias Brain Injury



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Patient’s Name/ID: _______________________________________________________ Previous Medical History: Allergies (adverse reactions to medications/food/etc.): ________________________________ PCP Name and Tel Number: ____________________________________________________ Date of Last Physical Exam: ____________________________________________________ Findings from Exam: ______________________________________________________ Any relevant medical conditions (diabetes, hypertension, head traumas, cardiac problems, asthma or other breathing problems, cancer, etc.): _____________________________________ ______________________________________________________________________________ Family Medical History: __________________________________________________________ Current medications (Include prescribed dosages, dates of initial prescription and refills, and name of doctor prescribing medication. Please include herbals and OTC meds): ____________________________________________________________________________________________________________________________________________________________ Hospitalizations/Surgeries (include dates, complications, adverse reactions to anesthesia, outcomes, etc.): ______________________________________________________________________________ ______________________________________________________________________________ Past Psychiatric History (Mental Health and Chemical Dependency): Hospitalizations: _______________________________________________________________ ______________________________________________________________________________ Family History of Suicide/Homicide: [] Yes [] No ______________________________________________________________________________ Prior Outpatient Therapy

Previous practitioners and dates of treatment: __________________________________ _______________________________________________________________________ _______________________________________________________________________ Previous treatment interventions: ____________________________________________ _______________________________________________________________________ _______________________________________________________________________ Response to treatment interventions including medications: _______________________ ________________________________________________________________________

Results of recent laboratory tests and consultation reports: ________________________________________________________________________ ______________________________________________________________________________ Family Mental Health or Chemical Dependency History: _____________________________ ________________________________________________________________________



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Patient’s Name/ID: _______________________________________________________ Psychosocial Information: Support Systems: _______________________________________________________________ School/Work Life: ______________________________________________________________ Marital History: ________________________________________________________________ Legal History: _________________________________________________________________ Military History: ________________________________________________________________ Spiritual Beliefs: ________________________________________________________________

Risk Assessment Ideations None

Noted/Denies

Thoughts Only

Plan Intent

Means Attempt

Able to Contract for

Safety Suicidal Ideation

Homicidal Ideation

*If significant risk was found (checklist) : ___Complete Risk Assessment form ___Assessed for diminishing access to weapons/lethal means ___Developed a plan for maintaining sobriety and discussing the role of substance (if applicable) ___Involved family/other support system members in suicide management plans ___Documented actual family/support system involvement Assessment of Risk Factors (check all that apply): ____ Non-compliance with treatment _____History of violence ____ AMA/elopement potential _____Insomnia ____ Prior behavioral health inpatient admissions _____Substance abuse ____ History of multiple behavioral diagnosis _____Anxiety ____ Suicidal/Homicidal ideation _____Other (describe) ____ Debilitating illness/Advanced age/Gender in seniors _____Gender identity disorder in teens

Substance Abuse History (complete for all patients age 12 and over) Substance Amount Frequency Duration First Use Last Use Caffeine Nicotine/Tobacco Alcohol Marijuana Opioids/ Narcotics

Amphetamines Cocaine Hallucinogens Others:



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Patient’s Name/ID: _______________________________________________________

CHILDREN AND ADOLESCENTS ONLY:

Developmental History (developmental milestones met early, late, normal): __________________ History of Head Injury? []Yes [] No _____________________________________________ History of Seizures? [] Yes [] No _____________________________________________ Perinatal History (details of labor/delivery): ________ ____________________________________________________________________________________________ Prenatal History (medical problems during pregnancy, mother’s use of medications): _______ _______ ____________________________________________________________________________________ ____________________________________________________________________________________ Strengths: ____________________________________________________________________ Barriers: _____________________________________________________________________ Referral to PREVENTIVE SERVICES for all patients (as appropriate): ___Relapse prevention ___Legal aid ___Stress management ___Financial aid ___Wellness programs ___Pastoral care ___Lifestyle changes ___Medical/Psychiatric Assessment ___Referrals to community resources ___Others: (describe) DIAGNOSTIC IMPRESSION: Axis I: Axis II: Axis III: Axis IV: ___Mild ___Moderate ___Severe Nature of Stressors: ___Family ___School ___ Work ___Health___ Other: (describe) Axis V: Current GAF: Highest GAF: Measurable Treatment Goal Intervention Timeframe for Achievement

Medication Education (as appropriate): ___ Yes ___N/A Patient Verbalizes Understanding: Crisis Plan: __________________________________________________________________ Initial Transition/Discharge Plan: _______________________________________________ FU Appt: ______________________ Clinician Signature: __________________________________ Date: ________________


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Progress Notes Template Patient’s Name/ID#:_______________________Date: _____________ Suicidal Ideation: ___ no ___ yes: describe: __________________________________________ Substance Use Issues: ___ no ___yes: describe: __________________________________________ Change in Mental Status Exam: Appearance: Affect: Orientation: Memory: Concentration: Attention: Mood: Speech: Motor: Thought Content: Thought Process: Impulse Control: Judgment: Clinical Assessment (progress toward goals):_________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Interventions:___________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Plan for crisis management: ___________________________________________________ Education: ______________________________ Member stated understanding: yes Medication Dose Preliminary Discharge Plan: ________________________________________________ Referral to Preventive Services (as appropriate): ________________________________ Clinician Signature:__________________________ Date:___________________

Follow-Up Appt: ________ Diagnosis, if changed: _________________


Treatment Plan Template All treatment goals must be objective and measurable, with estimated time frames for completion. The treatment plan is to be developed with the patient, and the patient’s level of understanding/ acceptance of the goals developed should be documented in the medical record.

Problem/Symptom Objective and Measurable Goal Intervention Completion Date



My therapist and I have developed this plan together, and I am in agreement to working on these issues and goals. I understand the treatment goals that were developed for my treatment.

Patient Signature:_____________________________ Date:________ Therapist Signature:______________________________ Date:_______

Name: _________________________________ Date:__________________

Treatment Plan Collaboration TO BE COMPLETED BY PATIENT: Please circle any items in the list below that you might have interest in learning more about: Assertiveness Training Problem Solving Skills Training Anger Management Solution Focused Techniques Affect Identification and Expression Stress Management Cognitive Restructuring Supportive Therapy Communications Training Self/Other Boundaries Training Grief and Loss Work Decision Option Exploration Imagery/Relaxation Training Pattern Identification and Interruption Parent Training Identify personal strengths Foster Care/Adoption Education Engage Significant Others in treatment TO BE COMPLETED BY THERAPIST and PATIENT Below are ways to accomplish some of the things circled in the list above. Facilitate decision making regarding: ________________________________________________________ Explore/Monitor: ______________________________________________________________________ Teach skills of: ________________________________________________________________________ Educate regarding: ______________________________________________________________________ Assign reading materials: _________________________________________________________________ Assign tasks of: _________________ _______________________________________________________ Referrals planned:_________________ _____________________________________________________ Use of resources/strengths:_______________________________________________________________ Preventive strategies:____________________________________________________________________

A copy of this should be kept in the patient record. Another copy should be given to the patient.


Treatment Plan Examples

All treatment goals must be objective and measurable, with estimated time frames for completion. The treatment plan is to be developed with the patient, and the patient’s level of understanding/ acceptance of the goals developed should be documented in the medical record. Treatment Goals Reduce risk factors of _________________________ by 90%. Reduce major symptoms of ____________________ by 80%. Ameliorate functional impairments of ______________ to once a week. Develop 3-4 coping strategies to deal with stress of ______________. Stabilize (short term) crisis of ____________ for up to 6 months. Maintain (long term) stabilization of symptoms of ____________ for up to 2 years. Medication referral to ________________ after termination.

Planned Interventions with Patient Participation (must be consistent with treatment goals) Assertiveness Training Problem Solving Skills Training Anger Management Solution Focused Techniques Affect Identification and Expression Stress Management Cognitive Restructuring Supportive Therapy Communications Training Self/Other Boundaries Training Grief Work Decision Option Exploration Imagery/Relaxation Training Pattern Identification and Interruption Parent Training Engage Significant Others in treatment____________________________________ Facilitate decision making regarding______________________________________ Explore/Monitor:_____________________________________________________ Teach skills of________________________________________________________ Educate regarding_____________________________________________________ Assign reading materials________________________________________________ Assign tasks of _______________________________________________________ Referrals planned _____________________________________________________ Use of resources/strengths:______________________________________________ Preventive strategies___________________________________________________ Obstacles to change____________________________________________________

Substance Abuse/Chemical Dependency Assessment

Client Name: Case #:

To be completed by clinician with client, or client's family member when screening indicates SA/CD issues GENERAL SYMPTOMS OF CHEMICAL DEPENDENCY (Check all that apply)

Preoccupation Daily Use Guilt or remorse Tolerance Loss of control A.M. drinking Hiding supply Prescription abuse Blackouts Pre-drinking Sneaking use Use to reward self Unable to stop Binging Use to reduce stress

Elaboration (include triggering events):

PHYSICAL – WITHDRAWAL SYMPTOMS OF CHEMICAL DEPENDENCY Tremors Delirium (DTs) Seizures High Blood Pressure Hepatitis Nosebleeds Ulcers Gastritis Other Symptoms:

BEHAVIOR – PERSONALITY CHANGES ASSOCIATED WITH USE Verbal abuse Social isolation Family concerned Physical abuse Labile mood Work concerned Excessive anger Depression Insomnia More/less social More relaxed Sexual performance Embarrassed by behavior during use Effects on morality or spirituality Un-kept promises

Elaboration:

FINANCIAL AND LEGAL HISTORY Wages garnished Bankruptcy Legal problems Repossessions Suspended license Collection agency involved

Indicate dates of arrest if applicable: DWI-DUI: Possession: Drug Sales: Burglary: Domestic Violence: Other: History of probation: _________

PROBLEMS IN JOB, SCHOOL OR OTHER ROLE FUNCTIONS

Attendance Deteriorating performance Promises to improve Tardiness Disciplined Mon or Fri absences Accidents/safety violations Argumentative Using at work/school Erratic behavior

TREATMENT HISTORY (Indicate dates of treatment)

Detoxification: Outpatient: Aftercare: Other: Inpatient: Longest abstinence:

SUBSTANCE ABUSE/CHEMICAL DEPENDENCE HISTORY (For client age 12 or over, please complete for each substance used including past use or substances not currently being used. Include over-the-counter medications, prescriptions, controlled substances, nicotine products, and alcohol.)

Client reports past history of use but is now abstinent: _____________________________

Substance: Amount Frequency Age began Last used

OTHER ADDICTIONS

Eating Gambling Sexual Spending Codependency Other

CHEMICAL DEPENDENCY ASSESSMENT SUMMARY

Chemical dependency apparent: Yes___ No___ Refer for evaluation of level of care: Yes___ No___ Chemical abuse apparent: Yes___ No___

Clinician Signature Credentials Date

©2004-2006 Magellan Health Services. This document is the proprietary information of Magellan. Rev. 3/06

(CES-D). Journal of Psychosomatic Research, 46, 437-443. Radloff, L.S. (1997). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

Name _________________________________ Date __________________

Depression Screening Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week by checking the appropriate space. During the past week

Rarely on None

Some or Little Occasionally or Moderate

Most or All of the time

I was bothered by things that usually don’t bother me.

0 1 2 3

I did not feel like eating; my appetite was poor

0 1 2 3

I felt that I could not shake off the blues, even with help from my family.

0 1 2 3

I felt that I was just as good as other people.

3 2 1 0

I had trouble keeping my mind on what I was doing.

0 1 2 3

I felt depressed. 0 1 2 3

I felt that everything I did was an effort.

I felt hopeful about the future.

3 2 1 0

I thought my life had been a failure.

0 1 2 3

I felt fearful. 0 1 2 3

My sleep was restless. 0 1 2 3

I was happy. 3 2 1 0

I talked less than usual. 0 1 2 3

I felt lonely. 0 1 2 3

People were unfriendly. 0 1 2 3

I enjoyed life. 3 2 1 0

I had crying spells. 0 1 2 3

I felt sad. 0 1 2 3

I felt that people disliked me.

0 1 2 3

I could not get ‘going.’ 0 1 2 3

Scoring Totals

The score is the sum of 20 item weights. Range is 0-60. If more than 4 questions are missing answers, do not score. A score of 16 or more is considered depressed.

Clinician Signature _______________________________________ Date _____________________

Suicide Risk Assessment Patient Name: ________________________________________________Date of Birth: ____________ Date of Assessment:

SUICIDAL IDEATION

Present yes no Passive yes no Active yes no

Access to means yes no Gun access yes no

Intent yes no Specify: Plan yes no Specify:

HISTORY

History of thoughts yes no History of attempts yes no Family suicide history yes no History of abuse in childhood yes no History of foster care/adoption yes no History of violent behavior yes no History of impulsive behavior yes no History of substance use/abuse yes no

History of self harm yes no Recent loss of family yes no Recent loss of job yes no Recent separation/divorce yes no Recent inpatient psych treatment yes no Violence in past year yes no Change in behavior yes no Was ideation shared? yes no

CURRENT RISK FACTORS

Familial/Social Support yes no Active psychosis yes no Depression yes no Substance use/abuse yes no Feelings of panic yes no Evidence of akathisia yes no Social isolation yes no

Terminal illness yes no Chronic pain yes no Traumatic brain injury yes no Male over 65 years yes no Sexual orientation issue yes no Feelings of anxiety yes no Recent Insomnia yes no

Level of Care necessary for safe treatment: ________________________________________________

Provider signature: Provider name (printed): Date: (revised 10/11)

Prescribing Guidelines for Atypical Antipsychotics

• Second-generation antipsychotics (SGA) have serious metabolic effects that must be monitored. They include weight gain, hyperglycemia, increased risk of type 2 diabetes, hyperlipidemia, agranulocytosis, serum prolactin elevation, cardiovascular effects and sudden death in the elderly with dementia-related psychosis.1

• With the exception of clozapine and olanzapine, clinical trials do not show a dose-dependent relationship between SGA and metabolic complications.2

• SGAs have demonstrated similar efficacy to first-generation antipsychotics (FGA) with fewer extrapyramidal symptoms (EPS) than FGAs at therapeutic doses (note: at higher doses the incidence of EPS with risperidone approaches FGA).1

• The use of more than one SGA concurrently is not recommended. This practice increases issues with non-compliance, drug interactions, side effects and cost effectiveness.3, 4

• The Texas Implementation of Medication Algorithms project does not recommend concurrent use of antipsychotics until stages 4 and 6 in its algorithm for schizophrenia. (Stage 4 is a combination with clozapine only).3, 4

• Secondary to the link between SGAs and metabolic adverse events, the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists and the North American Association for the Study of Obesity recommend the following screening measures for monitoring patients using atypical antipsychotics.5, 6 The screening measures pertain to all ages, metabolic adverse events have recently been reported in children and adolescents who have been prescribed these medications.7

Measure Baseline 4 weeks

8 weeks

12 weeks

Annually (or as clinically

indicated) Personal/Family History X X Body Mass Index X X X X X Waist Circumference X X Blood Pressure X X X Fasting Blood Glucose X X X Fasting Lipid Profile X X X White Blood Cell Count7

X X X X X

• An adequate trial of at least four weeks at therapeutic doses (three months for clozapine) is needed to assess adequate response before considering a switch to another agent. Full effects may not be seen for 12 weeks, sometimes longer.3, 8

• Promoting adherence to treatment is critical. Behavioral techniques that have been successful include the use of reminders, self-monitoring tools, cues and reinforcements.9

Revised March 2011

Revised March 2011

• Cognitive and motivational approaches that have been effective include reviewing the benefits and drawbacks of drug treatment, exploring sources of ambivalence, confronting stigma, pointing out discrepancies between the patient’s beliefs and actions, and focusing on adaptive behaviors.9

• The FDA has established black box warnings for the use of all antipsychotic medications, both first- and

second-generation antipsychotics, due to increased mortality in elderly patients with dementia-related psychosis.

• While there is some evidence suggesting that atypical antipsychotics are effective for certain psychiatric

disorders in children and adolescents, the majority of the studies are anecdotal or are short-term open-label trials.6

• The FDA has included Abilify®, Seroquel® and Seroquel XR® in its additional black box warning for

increased risk of suicidal thinking and behavior with the use of this class of medication in children, adolescents and young adults.10

These guidelines are not intended to replace a practitioner’s clinical judgment. They are designed to provide information and to assist practitioners with decisions regarding care. The guidelines are not intended to define a standard of care or exclusive course of treatment. Health care practitioners using these guidelines are responsible for considering their patient’s particular situation in evaluating the appropriateness of these guidelines.

1. Wolters Kluwer Health Inc. Facts & Comparisons E-Answers, 2010. Accessed November 29, 2010. 2. Simon V, et al. Are weight gain and metabolic side effects of atypical antipsychotics dose dependent? A literature

review. J Clin Psychiatry; 2009 Jul;70(7):1041-50. 3. Argo T, et al. Texas Medication Algorithm Project Procedural Manual: Schizophrenia Treatment Algorithms,

Revised April 2008. Available at http://www.dshs.state.tx.us/mhprograms/pdf/schizophreniamanual_060608.pdf Accessed November 29, 2010.

4. Goren J, et al. Development and delivery of a quality improvement program to reduce antipsychotic polytherapy. J Manag Care Pharm; 2010 Jul-Aug;16(6):393-401.

5. American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity (2004). Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care; 2004; 27(2):596-601.

6. Jin H, et al. Use of clinical markers to identify metabolic syndrome in antipsychotic-treated patients. J Clin Psychiatry; 2010;71(10):1273-1278.

7. Panagiotopoulos C, et al. First do no harm: promoting an evidence-based approach to atypical antipsychotic use in children and adolescents. J Can Acad Child Adolesc Psychiatry; 2010 May;19(2):124-137.

8. National Institute for Health and Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. NICE clinical guideline 82 (update of NICE clinical guideline 1). March 2009. Available at http://www.nice.org.uk/nicemedia/pdf/CG82NICEGuideline.pdf Accessed November 29, 2010.

9. Magellan Health Services. Introduction to Magellan’s Adopted Clinical Practice Guideline for the Treatment of Schizophrenia. Available at https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/clin_prac_guidelines/schizophrenia.pdf Revised 12/09. Accessed November 29, 2010.

10. FDA MedWatch - July 2009 Drug Safety Labeling Changes. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm172740.htm Accessed November 29, 2010

http://www.dshs.state.tx.us/mhprograms/pdf/schizophreniamanual_060608.pdf

http://www.nice.org.uk/nicemedia/pdf/CG82NICEGuideline.pdf

https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/clin_prac_guidelines/schizophrenia.pdf

https://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/clin_prac_guidelines/schizophrenia.pdf

http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm172740.htm

Metabolic Syndrome Monitoring Log Patient Name: ___________________________________

Risk Criteria2 Baseline 4 weeks

8 weeks

12 weeks Annually

Date of Assessment

__/___/__

__/___/__

__/___/__

__/___/__

__/___/__

Obesity Yes No Diabetes Yes No Dyslipidemia Yes No Hypertension Yes No Personal History Cardiovascular

Disease Yes No

Obesity Yes No Yes No Diabetes Yes No Yes No Dyslipidemia Yes No Yes No Hypertension Yes No Yes No Family History Cardiovascular

Disease Yes No

Yes No

Weight (BMI) Overweight: 25.0-29.9

Obese > 30.0

Waist Circumference

Males < 401 Females < 351

Blood Pressure

Fasting Plasma Glucose

IFG: 100-1251 mg/dL

Diabetes > 126 mg/dL

Fasting Lipid Profile

Total Cholesterol < 200 mg/dL1

HDL > 401 LDL < 1001 TG < 1501

Notes: ______________________________________________________________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

1 Normal Values 2 More frequent assessments may be warranted based on clinical status and specific anti-psychotic used


Discharge Summary Template (Must be completed within 60 days from last visit)

Patient’s Name/ID#: _____________________________ Date: ______________ Reason for Termination (was patient in agreement with termination at this time?) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ If patient did not return for scheduled appointment, was/were attempt(s) made to contact patient to re-schedule? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Discharge Medications:__________________________________________________ ______________________________________________________________________ Discharge DSM IV Axis I ___________________________________________ Axis II ___________________________________________ Axis III ___________________________________________ Axis IV ___________________________________________ Axis V ___________________________________________ Referral Options (if treatment goals were not met, appropriate referrals must be made)

1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________

Referred to preventive services as appropriate (for example): ___Relapse prevention ___Legal aid ___Stress management ___Financial aid ___Wellness programs ___Pastoral care ___Lifestyle changes ___Medical/Psychiatric Assessment ___Referrals to community resources ___Others: (describe) If patient has become suicidal, homicidal or unable to conduct activities of daily living during course of treatment, was patient referred to appropriate level of care? Explain: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Clinician Signature:__________________________________ Date: ______________

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