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).
Video # or Discussion Board Prompt #
Brief description of the patient
Brief explanation of the presenting symptoms
Any known medical history, allergies, etc.
Your psychiatric diagnosis (supported by the DSM-5).
List 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 (this includes ideation, intent, plan, means, etc.).
What psychiatric tools or scales you used (or that you would use) to help support your diagnosis (include citations).
Medications being ordered
Include name of medication(s) and what the med is used for (include citation)
Include the route, dosage, frequency (include citation)
Include black box warnings or what the pt needs to know/foods to avoid, etc. (include citation)
Non-pharmacological treatments that are being ordered (include citation that supports these).
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 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), and 1 scholarly journal article reference within the last 5 years, for each of the videos or discussion board prompts being assessed.
Transcript: [PATIENT:] I went to the emergency department last week, because I was feeling like I was dying from a heart attack, and they did one of those, what do you call it? Ah, an EKG. And it was normal. But I was sweating and I was having trouble like catching my own breath. And my heart was pounding really, really hard. And I, and I just felt like my, my heart was just going to explode out of my chest. It almost felt like, um, like when your…I don’t know, when you’re in the woods. Uh, alone and, and you… you, feel like someone is, is following or, or chasing you. Or something like that. I, I just, I just my heart felt like it was about to leap out of my chest. I… And uh… I don’t know, probably twelve, fifteen minutes went by and, and the feeling just went away. It just passed. But then… the next day, it was the very same thing and I, for no reason at all. Just all of a sudden, I was making coffee and then WAM, that, that, that tightness in my chest came back and I was sweating and my heart was pounding, same exact feeling. Twelve, fifteen minutes, and then it just went it away. It was like… almost it was almost like my mother, I remember she would get the same thing, probably three to four times a week. It’s just sheer panic for no particular reason at all.
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