Compliance Guidelines Made Easy: Part 3 Treatment Plan Reviews

Most clinicians don't realize that treatment plans are supposed to be updated with the client after every 3-5 encounters with the client.  In Intensive Outpatient, this means every week.  As soon as I tell clinicians that, they usually start to get very stressed.  In a traditional setting, with 15 clients being seen three hours per day, plus completing intakes and other duties as assigned and handling client crises, there is not a spare 8 hours to visit with each client for 30 minutes every week for a treatment plan update.  So, how can you comply?  It is easy really.

Each time the client comes to treatment, have them complete the following worksheet (or something like it)

Treatment Progress Review Worksheet

Name:                                                                              Date:

I am feeling:  Happy   Sad    Scared   Angry    Lonely    Bored    Frustrated    Other: ____

My biggest accomplishment this week was:

My biggest hurdle this week was:

Goal #1   This week for Goal #1 I worked on ____(identify the objective or subgoal)___

This is helping me by: ____________________________________________________

Modifications or changes I need to make (if any) are: ___________________________

I need help/guidance on: __________________________________________________

Next week I will being working on _____(identify the objective or subgoal)__________

Goal #2   This week for Goal #2 I worked on __________________________________

This is helping me by: ____________________________________________________

Modifications or changes I need to make (if any) are: ___________________________

I need help/guidance on: _________________________________________________

Next week I will being working on __________________________________________

Goal #3   This week for Goal #3 I worked on __________________________________

This is helping me by: ____________________________________________________

Modifications or changes I need to make (if any) are: ___________________________

I need help/guidance on: _________________________________________________

Next week I will being working on __________________________________________

In Intensive Outpatient Settings,  clients can review this worksheet in group, get positive feedback from their peers about their progress on that objective, and receive support, encouragement and suggestions for any areas in which they may be struggling.   This worksheet then becomes part of the client's treatment record.

Again, by altering the way we "typically" approach documentation we are assisting the client in learning how to set and systematically achieve goals and maintain motivation through social supports and accountability.  A side benefit is that clients also get to practice providing positive and constructive feedback.

When the client meets with their counselor for individual counseling, the brunt of the work is already done, so the majority of that session can be spent doing active counseling, not compliance activities.