Treatment Plan Template with Examples

Treatment Plan Template

This treatment plan template is suitable for practitioners of all background, even though it was designed by a mental health clinician. The template includes sections for diagnosis, presenting problems, treatment goals, objectives, and interventions, as well as discharge planning and additional information. 

• Helps clinicians document client goals, measure progress and outline treatment strategies.
• Uses a generic structure that can be utilized in most practice settings.
• AI prompts automatically include patient quotes about their goals for treatment.

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What is a Treatment Plan Template?

A treatment plan template serves as a roadmap for care, ensuring all parties understand the direction and purpose of treatment. Most treatment plan templates include sections to describe the patient’s diagnosis, goals, objectives of treatment, and interventions that may be used. Treatment plans may be used by any healthcare practitioner and they are usually reviewed at set intervals.

A defining feature of the treatment planning process is that it is patient-centered. Goals should be chosen by the patient and be meaningful in the context of their health concerns and treatment preferences.

Roles and responsibilities may also be outlined in a treatment plan template, with the completed (and signed) document serving as an informal “contract” or consent form between the clinician and patient.

In this article, we’ll explore the benefits of using a treatment plan template and discuss ways to approach goal setting. An example of a well-structured treatment plan is also provided, along with free AI-powered templates you can start using immediately.    

Benefits of Using a Treatment Plan Template

Clinicians of all backgrounds utilize treatment plans. In some situations, there will be a mandated organizational treatment plan template that must be followed. While in others, the practitioner may choose to develop their own template as a practice improvement strategy.  

A well-designed treatment plan template ensures that the practitioner covers all essential components of the planning process. This helps both the patient and clinician derive the full benefits of developing a treatment plan, which are detailed below.

Enhanced Patient Engagement

Treatment plan templates can improve patient engagement by prompting patients to actively participate in developing goals and treatment strategies. This collaborative process encourages the patient to adopt a sense of ownership over their care journey, increasing treatment adherence and motivation.

An example of this in practice would be a substance abuse treatment plan template with specific instructions to include patient quotes about goals.

Giving a patient a copy of a treatment plan with a personal statement like, “My goal is to stay sober so I don’t lose contact with my children,” is more powerful than a generic goal like, “Patient wants to stop drinking.”

Improved Clarity and Communication

A well-structured treatment plan template ensures the patient, treating clinician, and any other involved professionals understand the overall direction and purpose of treatment. Other types of clinical documentation, such as progress notes, are still completed, but the treatment plan serves as an anchor that’s referred back to for guidance.

Treatment plans are especially useful for promoting effective communication in multidisciplinary settings. For example, several clinicians working with the same patient might use an inpatient behavioral treatment plan template. Such an approach ensures all providers work in a coordinated way that aligns with the patient’s treatment goals.     

Measurable Progress Tracking

Including goals, objectives, and interventions in treatment plan templates makes them ideal for objectively measuring a patient’s progress and response to treatment.

By periodically reviewing a treatment plan to revisit progress and goals, the patient and clinician can celebrate successes, address obstacles, and adjust the treatment plan if the current interventions are not effective.

A counseling treatment plan template might implement progress tracking by including outcome measures in the planning process. For example, if a patient is attending counseling for anxiety management, the Hamilton Anxiety Rating Scale (HAM-A) or Beck Anxiety Inventory (BAI) could be repeated at each scheduled treatment plan review.

Insurance and Statutory Compliance

Many insurance providers and regulatory bodies require documented treatment plans for reimbursement and compliance purposes. This is especially common in rehabilitation, mental health, and long-term care settings where justification for ongoing services is required.

Where treatment plan completion is mandatory, a well-structured template supports clinicians to efficiently develop compliant treatment plans. Through structured prompts for gathering information, a treatment plan template makes it easy to collect and present all necessary information in a format that meets insurance or statutory requirements.

To give an example of just how much time a well-designed template can save, Neil Aitken, physiotherapist and clinic owner, saves 1 - 2 hours per day in documentation time with custom templates in Heidi’s AI medical scribe. This reduced administrative burden allows him to get home earlier to spend time with his kids and have more time and energy to put into his clinical work and business.

The Template Community within Heidi also contains dozens of field-tested, free-to-use templates for every clinical specialty.

Medicolegal Protection

Treatment plan templates help ensure comprehensive documentation of clinical reasoning, planned interventions, consent to treatment, and patient and clinician roles and responsibilities.

In the case of complaints, audits, or legal proceedings, treatment plans can form part of the evidence that appropriate care was planned and delivered according to the patient's wishes and preferences.

To illustrate this point, consider a dental treatment plan template for a patient who is an active cigarette smoker and has poorly controlled diabetes. In a plan for a bone graft and implant, the patient roles and responsibilities section may be used to detail required actions by the patient to reduce the risk of treatment failure.

Should the patient not follow these directions and experience a negative outcome, a well-written treatment plan offers some protection for the clinician in the case of a complaint.  

SMART Goal Setting with Treatment Plan Templates

Goal setting makes clinical documentation unique compared to most other types of clinical notes.

Unfortunately, while it’s generally agreed that goal setting is a key component of ongoing medical care, research suggests that clinicians often struggle with this vital aspect of practice.

One way to make goal setting easier is embedding a framework for developing high-quality goals directly into a treatment plan template. Perhaps the most well-known (and studied) goal setting framework is SMART, which stipulates that goals should be:  

• Specific - Goals should clearly define what the patient wants to achieve.
• Measurable - Goals must include criteria for measuring progress. and patient to 
• Achievable - Realistic and attainable goals are ideal.
• Relevant - Each goal should align with the patient’s health and personal needs.
• Time-bound - A timeframe for the achievement of each goal should be set. 

The difference between “regular” goals and SMART goals can be striking.

For example, when not guided through the SMART process, a patient may select a goal to “feel less depressed.” However, if the clinician supports them to transform this into a SMART goal to add to the treatment plan, the same initial goal might become:

Example SMART Goal

“I will reduce my depression symptoms as measured by a decrease of at least 5 points on the BDI scale within 8 weeks by attending weekly CBT sessions, sticking to my behavioral activation plan, and practicing daily mindfulness exercises.” 

How to Write a Treatment Plan with Examples

Treatment plans may vary in structure and content according to clinical setting and organizational requirements. However, most share a common set of essential components laid out in a templated structure. 

A good treatment plan template contains headings to cover all topics below, with potential discipline-specific additions.

Presenting Problem

The presenting problem section describes the specific issues that brought the patient to treatment. In this opening part of the treatment plan, the clinician should list the patient’s symptoms, concerns, diagnoses, and how these problems affect their daily functioning. Some clinicians also describe the patient’s medical history and a case formulation.

A good guiding principle for describing the presenting problem in a treatment plan is to include enough details to justify the need for treatment while also providing adequate context for goals and interventions.

Example:

John is a 42-year-old male who self-referred for treatment of increasing anxiety symptoms over the past 6 months. He reports persistent worry about work performance, financial stability, and family responsibilities that has become "uncontrollable" in recent weeks.

Physical symptoms include tension headaches, sleep disturbance (difficulty falling asleep, averaging 5 hours per night), restlessness, and occasional heart palpitations. 

John states, "I can't turn my mind off even for a minute. I'm constantly on edge and it's affecting my relationships." He reports his anxiety is interfering with his ability to concentrate at work, causing him to miss deadlines and receive negative feedback from his supervisor. His anxiety is self-rated as 8/10 in severity. GAD-7 score is 17, indicating severe anxiety.

Previous treatment includes a brief course of anxiolytic medication (lorazepam) prescribed by his primary care physician 3 months ago, which John discontinued due to concerns about dependence.

Goals and Objectives

The goals and objectives section of a treatment plan template describes the aims of treatment, focusing on the patient’s desired outcomes. This section should be completed collaboratively, with the clinician’s primary role being to support the patient through the goal setting process. 

Prompts to follow the SMART framework are sometimes included in the goals section of a treatment plan template. However, you may use an alternative goal-setting process if preferred. Long-term goals may be appropriate, but it’s generally best to focus on 2 - 4 goals the client is ready to work on immediately. 

Example:

1. Reduce the severity of my anxiety to an average of 5/10 by trialing a new medication and going to therapy. I aim to achieve this within 4 weeks.
2. Ask for accommodations at work for my health issues. I will have started the formal accommodations process with HR within 1 week.   

Interventions and Actions

With goals identified, it’s time to list exactly what the clinician and patient will do to achieve them. Remember to think holistically for this section, recording both medical treatments and general tasks or actions to be completed by the clinician and patient.

Interventions and actions should be tied to one of the goals from the previous section. If you find yourself with an action that doesn’t neatly link to a goal, it may be necessary to return to the previous section to create a new goal.

Example:

Actions for Goal 1 (Reduce the severity of my anxiety)

• Commence Sertraline 50 mg per day - psychiatrist to provide prescription today.
• Attend therapy weekly - patient to contact previous psychologist for an appointment.

Actions for Goal 2 (Ask for accommodations at work)

• Patient will speak to supervisor about health issues and request flexible deadlines as an interim measure.
• Patient will schedule an appointment with HR to discuss the accommodations process.
• Psychiatrist will provide a preliminary medical certificate/letter supporting the accommodations request (with further documentation as required) 

Additional Information

Most treatment plan templates include a final section for additional comments.

In the example case used above, the final section might detail a formal risk assessment completed by the psychiatrist. Or, in a family therapy treatment plan template, additional information could be a summary note written by the therapist to the couple.

In a medical environment, such as with a chemotherapy treatment plan template, a closing section may include instructions to the MDT or facility providing ongoing care.

A well-designed treatment plan template makes completing this valuable documentation easier. However, with the highly structured approach and number of topics to cover, some clinicians find the process can become a bit “mechanical” and lacking in genuine interaction with the patient.

Fortunately, it’s now possible to use AI to automatically generate treatment plans, leaving you free to engage fully with your patients. 

Create Effortless Treatment Plans with Heidi

Heidi’s AI medical scribe makes writing treatment plans a breeze. Just press “Transcribe” and conduct your planning session as normal while Heidi processes the entire clinical encounter. When finished, Heidi automatically collates all information from the session into an editable treatment plan, according to the format of your chosen template.

• Step 1 - Press “Transcribe” and conduct your session as usual.
• Step 2 - Select your preferred treatment plan template.
• Step 3 - Review the treatment plan generated by Heidi.

Since launch, Heidi’s AI scribe has supported clinicians in over 20 million patient interactions globally. Wrapped in world-class security standards, Heidi complies with region-specific healthcare data safety regulations, such as HIPAA, PIPEDA, GDPR, and more.

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Free Treatment Plan Templates

Therapy Treatment Plan Template

Designed for mental health practitioners to document comprehensive management plans, this therapy treatment plan template includes sections for diagnosis, treatment goals, prescribed medications, non-pharmacological therapies, lifestyle recommendations, follow-up plans, patient education, and referrals. 

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Mental Health Treatment Plan Template

This mental health treatment plan template facilitates a comprehensive assessment for clinicians to thoroughly evaluate a patient's mental health status. It includes a full biopsychosocial assessment, case formulation, mental status examination, and formal outcome measures.

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Substance Abuse Treatment Plan Template

This case formulation template incorporates the 4Ps framework to build a detailed substance abuse treatment plan template. It includes sections for client goals, presenting problems, and predisposing, precipitating, perpetuating, and protective factors. It also has prompts for a problem list, treatment goals, and a detailed case formulation.

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FAQs About Treatment Plan Templates

What are the four elements of a treatment plan template?

A treatment plan template always includes sections to discuss the presenting problem, goals, interventions, and actions to be completed by the clinician and patient. Outside of this, clinicians and organizations may include additions specific to the practice area and clinical specialty. 

How often should a treatment plan template be updated?

The time between updating treatment plan templates depends on the clinical setting and individual patient needs. As a basic guide, inpatient treatment plans in rehabilitation settings are usually updated every 2 - 4 weeks, while outpatient treatment plan reviews commonly occur every 2 - 6 months.

Can I make my own treatment plan template?

Heidi offers several options to easily create your own treatment plan template. You can: 1) Give Heidi a reference treatment plan to turn into a template; 2) Adapt an existing treatment plan template from the community; 3) Build your own treatment plan template from scratch. Read our Help Centre Article on Creating Templates in Heidi for full instructions.