How to Compile and Preview Treatment Plan

How to Compile and Preview Treatment Plan

Overview 

This knowledge base article provides guidance on documenting treatment plan progress. Once a treatment plan is added, you can record the following details:

 

  • Problem-Manifestation Details
  • Long-term Goals
  • Short-term Goals
  • Interventions
  • Strengths
  • Barriers
  • Plan Status

 

After documenting these details in the treatment plan, you can compile them to display in the note.

 

 

Update Treatment Plan Progress

After adding a treatment plan, you can update progress by clicking the Update Progress button as shown in the screen below:

 

 

 

 

When updating progress for a treatment plan, the following screen will appear, allowing you to record manifestations, long-term goals, short-term goals, interventions, strengths, and barriers.


The Plan Status tab on this screen allows you to record SNAP assessments and BPRS 18. After recording the treatment progress, you can click on the Compile tab.

 

All these sections are explained with screenshots later in the document.

 

 

 

Problem Manifestation Details

When updating progress for a treatment plan, the first step is to add manifestation details. To do this, you must add problems. Click the Add Problem button, as highlighted in the screen below.

 

 

 

The Add Problem screen appears as shown below. To add a new problem, click the Add New button. You can add multiple problems one after another by repeatedly clicking the Add New button.

 

 

 

When you add a problem, it appears in the list as shown below.

 

When you add a new problem, you will see the following options in the Discipline dropdown:

 

  • Rehab
  • Medical
  • Social
  • Psych

 

 

Based on your selection in the Discipline column, you will see the associated problems in the Problem dropdown. 

 

 

 

The problem you have added will appear in the Problem dropdown on the top left side of your screen as shown below. You can change the problem from the dropdown list once you record manifestation details for the selected problem.


The Problem Manifestation Details screen is divided into four sections as highlighted below:

 

  1. Manifestation: In this section, you can select the desired manifestation for the selected problem. It will appear with the Selected tag in green on the extreme right side.
  2. Manifestation Details: Based on your selected manifestation in section 1, the manifestation details will appear in section 2. You can select one or more manifestation details in this section.
  3. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each manifestation detail you have selected. If you select 3 manifestation details, you will see 3 yellow cards in this section. You can update manifestation details in the yellow card, they will appear in the preview pane on the right accordingly.
  4. Preview Pane: This section will display the shrub content that you have selected in the left pane. This is a preview of the manifestation details you have selected so far.

 

 

 

Add Custom Problems in the Treatment Plan 

When the desired problems do not appear in the list, you can add custom problems to the Treatment Plan.

 

Within the Problem-Manifestation Details tab, click the Manage Problem List link as shown in the screen below: 

 

 

 

On the Manage Problem List screen, while adding a new problem, if you don't find the required problem in the list, you can start typing the desired problem as shown below:

 

 

 

Once you type in the custom problem and click on the Add Custom Problem link, you will be redirected to the following screen to add custom content. 

 

The button name automatically populates, you can proceed to add variations in the designated boxes and click Save as shown in the screen below:

 

 

When you save the custom content, the problem details appear in the preview pane as shown in the screen below.

 

 

 

 

Long-term Goals 

You can record long-term goals for the problems of your client. The Long-term Goals screen is divided into three sections as highlighted below.

 

 

  1. Long-term Goals: In this section, you can select the desired long-term goals for the selected problem. It will appear with the Selected tag in green on the extreme right side.
  2. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each long-term goal you have selected. If you select 2 long-term goals, you will see 2 yellow cards in this section. You can update long-term goals shrub content in the yellow card, it will appear in the preview pane on the right accordingly.

    You can also record the progress of long-term goals in this section.

    * Progress: The following are the options to record the long-term goal progress: Working on, Partially complete, Plans to start soon, Almost done, Completed, Decided not to complete.
    * Target Date: Select the target date for the problem. It will appear in the preview pane.
    * Completion Date: Select the completion date for the problem. It will appear in the preview pane.

  3. Preview Pane: This section will display the shrub content that you have selected in the left pane. This is a preview of the long-term goals and the progress you have selected so far.

 

Note: If you want to add a new problem while working on long-term goals, you can do it by clicking on the Manage Problem List link next to the Problem dropdown.

 

 

Short-term Goals 

You can record short-term goals for your client's problems. This screen displays all the manifestations you have recorded for the selected problem. If you need to add a manifestation at this time, you can do so by clicking the Add Manifestation link.

The Short-term Goals screen is divided into four sections, as highlighted below.

 

You can record short-term goals for your client's problems. This screen displays all the manifestations you have recorded for the selected problem. If you need to add a manifestation at this time, you can do so by clicking the Add Manifestation link.

 

  1. Manifestations: In this section, you can select the manifestations for which you want to record the short-term goals. Each manifestation will appear as a capsule. If you want, you can add a new manifestation in this section.

  2. Short-term Goals: In this section, you can select the desired short-term goals for the selected manifestation. It will appear with the Selected tag in green in the extreme right side.

  3. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each short-term goal you have selected. If you select 2 short-term goals, you will see 2 yellow cards in this section. You can update short-term goals shrub content in the yellow card, it will appear in the preview pane on the right accordingly.

    You can also record the progress of short-term goals in this section.

    * Frequency: Select frequency from the dropdown list. It could be, twice, thrice, and so forth.
    * Time Period: Select the period from the dropdown list. It could be any of the following: Per day, Per week, Per month, Per session, Per shift, Per minute, Per hour, Per morning, Per afternoon, Per quarter, Per year, Per episode.
    * Duration: Select duration from the dropdown list. It could be, forever, 5 mins, 10 mins, and so forth.
    * Progress: The following are the options to record the long-term goal progress: Working on, Partially complete, Plans to start soon, Almost done, Completed, Decided not to complete.
    * Status: Select status from the dropdown list. It could be Effective or Ineffective.
    * Target Date: Select the target date for the problem. It will appear in the preview pane.
    Completion Date: Select the completion date for the problem. It will appear in the preview pane.

  4. Preview Pane: This section will display the shrub content that you have selected in the left pane. This is a preview of the short-term goals and the progress you have selected so far.

 

Interventions 

You can record interventions for each short-term goal in this section. You can first select the discipline from the dropdown list for which you want to record short-term goals. The discipline could be Case Manager, Dietitian, Group Therapist, Nurse, and so forth. When you select the discipline, it will allow you to select the short-term goals to record interventions. If you want to add more short-term goals at this moment, then also you can add them by clicking on the Add Short-term Goal link.

The Interventions screen is divided into five sections as highlighted below.

 

  1. Discipline: In this section, you can select the discipline for which you want to record interventions for the short-term goals. You will see below options in the Discipline dropdown: Case Manager / Team Leader, Dietitian, Group Therapy, Nursing, OT/PT/Recreation, Psychiatrist/Prescriber, Psychologist, Therapist/Counselor, and Unlicensed Professional.  
  2. Short-term Goals: In this section, you can see all the short-term goals you have recorded for the problem. You can record interventions for each short-term goal for the selected discipline. Each short-term goal will appear as a capsule. If you want, you can add a new short-term goal in this section.
  3. Interventions: In this section, you will see all the interventions for the selected short-term goals. When you record interventions, they will appear with the Selected tag in green on the extreme right side.  
  4. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each intervention you have selected. If you select 2 interventions, you will see two yellow cards in this section. You can update interventions shrub content in the yellow card, it will appear in the preview pane on the right accordingly.

    You can also record the following details for interventions in this section.

    Frequency: Select frequency from the dropdown list. It could be, twice, thrice, and so forth.
    Duration: Select duration from the dropdown list. It could be, forever, 5 mins, 10 mins, and so forth.
    Period: Select duration from the dropdown list. It could be, forever, 5 mins, 10 mins, and so forth.  
    Clinician: Select the clinician from the dropdown list.

  5. Preview Pane: This section will display the shrub content that you have selected in the left pane. This is a preview of the interventions you have selected so far.

 

 

Strengths 

You can record the strengths of clients in this section. The Strengths tab is divided into four sections as highlighted below.

 

 
  1. Comprehensive Plan Strengths: In this section, you can select one or more strengths for the client. They will appear with the Selected tag in green on the extreme right side.
  2. Strength Details: Based on your selected strengths in section 1, their details will appear in section 2. You can select multiple options for strength details in this section.
  3. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each strength detail you have selected. If you select 3 strength details, you will see 3 yellow cards in this section. You can update strength details in the yellow card, they will appear in the preview pane on the right accordingly.
  4. Preview Pane
    : This section will display the shrub content that you have selected in the left pane. This is a preview of the strengths you have selected so far.

 

Barriers 

You can record the barriers the client is facing. The Barriers tab is divided into four sections as highlighted below.

 

 

  1. Comprehensive Plan Barriers: In this section, you can select one or more barriers for the client. They will appear with the Selected tag in green on the extreme right side.
  2. Barrier Details: Based on your selected barriers in section 1, their details will appear in section 2. You can select multiple options for barrier details in this section.
  3. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each barrier detail you have selected. If you select 3 barrier details, you will see 3 yellow cards in this section. You can update barrier details in the yellow card, they will appear in the preview pane on the right accordingly.
  4. Preview Pane: This section will display the shrub content that you have selected in the left pane. This is a preview of the barriers you have selected so far.

 

Plan Status 

In Plan Status, you can record the client’s supplemental information as well as record plan status details such as Initial Plan, Progress in Meeting Goals, and Recommendations. The Plan Status details you record will appear in the preview panel on the right side.

 

Initial Plan, Progress in Meeting Goals, and Recommendations 

The Plan Status section is divided into five sections.

 

 

  1. Plan Status Selection: In this section, you can select the desired option from Initial Plan, Progress in Meeting Goals, and Recommendations. Based on your selection, you will find the details in the next section (section# 2) for further selection.
  2. Details for Plan Status: Based on your selected plan status in section 1, their details will appear in section 2. For example, if you have selected the Initial Plan option in Section 1, its relevant details will appear in this section. Similarly, when you select the Progress or Recommendations options in Section 1, its relevant details will appear in this section. The Plan status details will appear with the Selected tag in green on the extreme right side.
  3. Yellow Card (Shrub Content): In this section, you can see shrub content in the yellow card for each plan status detail you have selected. If you select 3 options in plan status details, you will see 3 yellow cards in this section. You can update plan status details in the yellow card, they will appear in the preview pane on the right accordingly.
  4. Preview Pane: This section will display the shrub content that you have selected in the left pane. This is a preview of the plan status you have selected so far.
  5. Supplemental Information: Section # 5 (supplemental information) highlighted in the screen above is explained later in this document.

 

SNAP Assessment 

In the Plan Status tab, you can click on the SNAP Assessment button to record the SNAP assessment details. When you record the details, they will appear in the preview pane as highlighted in the screen below.

 

 

When you click on the SNAP Assessment button, it opens the screen as shown below. You can select the desired options from the left pane (section 1 below), and the shrub content will automatically be formed in the yellow card in the right pane (section 2 below). You can make the desired edits in the yellow card as per your need. Accordingly, it will appear in the preview pane in the SNAP section.

 

 

BPRS 18 (Brief Psychiatric Rating Scale) 

In the Plan Status tab, you can click on the BPRS18 button to record the Brief Psychiatric Rating Scale details. When you record the details, they will appear in the preview pane as highlighted in the screen below.

 

 

When you click on the BPRS18 button, it opens the screen as shown below. You can select the desired options from the left pane (section 1 below), and the shrub content will automatically be formed in the yellow card in the right pane (section 2 below). You can make the desired edits in the yellow card as per your need. Accordingly, it will appear in the preview pane in the Brief Psychiatric Rating Scale section.

 

 

Review Medications 

When you prescribe any medications for the client, they will appear in the Review Medications tab within the Plan Status section. If there are none, the system will display a screen as shown below.

 

 

Review Diagnosis 

When you record diagnosis codes for the client in the notes, they will appear in the Review Diagnosis tab within the Plan Status section as shown below.

 

 

 

 

 

Justification of Care 

 

The Justification of Care option in the Plan Status tab allows you to record the details using shrub content as shown below.

 

 

When you click on the Justification of Care button, it opens the screen as shown below. As you select the shrub content, it appears in the yellow card in the right pane. When you save the shrub content, it appears in the Preview pane as highlighted in the screen above.

 

 

Compile and Preview

Once you record treatment plan details for all the relevant sections, you can compile and preview the treatment plan. When you compile the treatment plan, you can locate all the details you have recorded in the preview pane on the right side. The details include problem manifestation details, long-term goals, short-term goals, interventions, strengths, barriers, and plan status.

 

 

As highlighted in the above screen, on the right pane, you can preview all the details you have recorded in the treatment plan. Once reviewed the details, you can click the Compile and Preview button to compile the treatment plan.

 

Treatment Plan Hierarchical View

When you access the treatment plan, you can record this icon in the top left corner of your screen that allows you to display the hierarchical view of the treatment plan.

 

 

 

When you click this icon, the hierarchical view of treatment plan will appear as shown in the screen below.

 

 

FAQs 

You can find the Frequently Asked Questions (FAQs) on our Knowledge Base page.


Click here for quick access to the FAQs.

 

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Need additional assistance?

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Text: 866-301-0085

Email: ticket@icanotes.com

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Proprietary Notice Information: This article is provided for informational purposes only, and the information herein is subject to change without notice. While every effort has been made to ensure that the information contained within this article is accurate, ICANotes cannot and does not accept any type of liability for errors in, or omissions arising from the use of this information.


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