A treatment plan is a therapist’s plan for care, developed in consultation with the client, for either a single session or multiple treatments. It is based on the client’s health history, input, and both pre-treatment and in-treatment assessments. The plan should be included in the client’s written treatment notes, with any updates or progress documented during multiple sessions.
Treatment plans are essential because they explain the “why” and “how” of the treatment, showing the therapist’s due diligence in meeting the client’s needs. Health insurance companies often review treatment plans during audits. Failure to include a plan in a client’s records could lead to denied claims, repayment of claims, or loss of recognition as a treatment provider.