A Treatment Plan, very simply put, is the plan for treatment that a therapist in consultation with their client puts in place for either a single treatment or multiple treatment sessions. This plan should be based on health history, client input, pre-treatment assessment and in treatment assessment. Treatment plans are to be part of the written treatment notes that are maintained in a Client’s Record. When a multiple treatment approach is used, it is important for the therapist to document any changes to the treatment plan, and to document progress that has been made with each treatment session.
Treatment plans are important because they provide the “why” and the “how” for treatment delivery. They show the due diligence that a therapist has taken in providing treatment that is focused on the needs of the client. When a health insurance company conducts an audit of treatment records, this is one element that investigators will be looking for within the Client’s Record. Failure to have a treatment plan within your client record may result in a claim being denied, or having to be repaid by the therapist, and may also result in a company denying a therapist future recognition as a treatment provider.