Behavioral Health Treatment Plan (Medical Setting)

Plan Type: [Initial / Update / Discharge]   Created: [date/time]   Effective Date: [start date]   Review Due: [anticipated review date]
Patient: [name and secondary identifier]   Author: [name, credentials, role]   Service Line/Program: [integrated BH / consult-liaison / embedded primary care BH / other]   Setting: [clinical setting and modality]   Referring Clinician: [name and role if applicable]

(If Update: include "Supersedes plan dated [prior plan date].")

Participants and Consent

Participants: [Names and roles of all participants in plan development] (Include patient, caregivers, interpreters, and relevant team members.)

Patient-stated priorities: [Patient's goals in their own words] (Quote or succinctly paraphrase.)

• Consent for BH treatment: [granted / declined]
• Consent for care coordination: [granted / limited / declined] (Specify scope and any restrictions.)
• MBC disclosure: [Patient informed that standardized tools will track progress]
• (If patient declined participation or signature, document declination and reason if offered. Do not infer consent from attendance.)

Clinical Summary

[Concise clinical formulation explaining why this plan, why now] (Include presenting BH concerns and functional impact in the medical setting, key contributing factors such as medical illness burden and psychosocial stressors, relevant history, and patient strengths/protective factors. Keep to 3–5 sentences; avoid duplicating full intake.)

Diagnoses and Problem List

Behavioral Health Diagnoses: [Primary BH diagnosis with ICD-10 code]; [Comorbid BH diagnoses with codes] (Use provisional/working diagnosis language when appropriate; note what will clarify.)

Relevant Medical Diagnoses: [Medical diagnoses materially affecting BH treatment] (Include only when treatment-relevant.)

Problem List (Order by clinical priority and safety.)

• [Problem 1 name]: [Severity/acuity] (If scale-derived, include tool, score, and date.) — [Functional impact in current medical context] — [Key maintaining factors]
• [Problem 2 name]: [Severity/acuity] — [Functional impact] — [Maintaining factors]

Safety Assessment

• Suicide risk screening: [tool, date, result] (Always document basis for determination.)
• Risk assessment (If positive screen or clinical concern):
  • Risk factors: [identified risk factors]
  • Protective factors: [identified protective factors]
  • Current risk level: [low / moderate / high] — [rationale]
  • Mitigation plan: [safety planning, crisis resources, monitoring plan, follow-up interval matched to risk level]
• Other safety domains: [violence risk / NSSI / substance withdrawal / capacity concerns / medication risks] (Include only as clinically indicated.)
• (If screening not completed, document reason and plan for completion. Never infer low risk without documented assessment basis.)

Treatment Goals and Objectives

Overarching patient-centered goals: [1–3 goals reflecting patient priorities in patient language]

• [Problem 1 name]
  • Long-term goal: [Functional or outcome-focused goal individualized to patient context]
  • Objective 1: [Specific, measurable, time-bound objective] — Measure: [tool or metric] — Baseline: [value, date] — Target: [value, timeframe]
  • Objective 2: [Specific, measurable, time-bound objective] — Measure: [tool or metric] — Baseline: [value, date] — Target: [value, timeframe]
• [Problem 2 name]
  • Long-term goal: [Functional or outcome-focused goal]
  • Objective(s): [As above with measure, baseline, target]

(If validated tool not appropriate due to cognitive, language, or other factors, document alternative metric and reason. If patient priorities not yet known, document plan to elicit them.)

Interventions and Services Plan

• [Problem 1 name]
  • Clinical interventions: [Psychotherapy approach, psychoeducation topics, behavioral assignments]
  • Care management: [Outreach, barrier mitigation, navigation, coordination tasks] (If applicable.)
  • Medication-related: [Current psychotropics or prescriber of record, planned adjustments, monitoring, adherence supports] (If applicable.)
  • Responsible party: [Role and name]
  • Setting/modality: [clinic / bedside / telehealth / phone / group]
  • Frequency and duration: [Sessions per time period; minutes per session] (If not yet determined, document initial range and decision point.)
  • Anticipated episode length: [Duration and review points]
  • Stepped care criteria: [Criteria for stepping up or down] (If using stepped care.)
  • Referrals: [Service, date placed, follow-up responsibility assigned]
• [Problem 2 name]
  • [Intervention details as above]

Measurement-Based Care Plan

• Selected measures: [Domain: tool] (e.g., Depression: PHQ-9; Anxiety: GAD-7) — [Brief rationale and population considerations]
• Administration schedule: [Baseline timing] — [Reassessment cadence] — [Who administers] — [Where recorded]
• Action thresholds:
  • Non-response: [Criteria and timeframe] → [Action]
  • Response/remission: [Criteria] → [Action]
  • Escalation triggers: [Worsening scores / safety concerns / functional decline] → [Psychiatric consultation / medication adjustment / modality change / increased frequency / LOC evaluation]
• (If measure incomplete, document reason and plan. Do not carry forward prior scores without date and source.)

Care Coordination Plan

• Care team: [Role: Name] (List PCP/specialist, BH clinician, care manager, psychiatric consultant, nursing, social work, outside providers, family supports.)
• Communication: [Channel] at [frequency] (e.g., EHR messaging weekly, huddles daily, case conference monthly.)
• Update content: [Treatment recommendations / MBC scores and trajectory / risk status changes / medication recommendations / adherence barriers / functional goals]
• Transition planning: [Anticipated transitions and handoff plan with responsible parties and timeline]
• External coordination: [ROI status: obtained / pending / declined] — [Contacts made or outreach planned with assigned responsibility]

Barriers and Supports

Barriers: [Identified barriers to engagement] (e.g., transportation, financial, scheduling, language, digital access, health literacy, cognitive, stigma.)

Supports: [Available resources] (Family, community, peer, spiritual, cultural.)

Mitigation actions: [Referrals, accommodations, interpreter arrangements, scheduling adaptations]

(Omit this section if no significant barriers identified.)

Review and Transition Planning

• Planned review interval: [Timeframe or visit count]
• Early update triggers: [Significant score change / hospitalization / safety event / major medication or medical status change]
• Discharge/transition criteria: [Symptom thresholds] — [Functional targets] — [Stable medical engagement] — [Step-down supports in place]
• Relapse prevention (When approaching goals or stepping down): [Early warning signs] — [Coping plan] — [Follow-up schedule] — [Re-engagement pathway]

(If too early for detailed discharge planning, document anticipated criteria.)

Signatures

Clinician Signature: [Signature, credentials, date/time]

Patient/Guardian Acknowledgment: [Signature and date] (Or note if declined with reason if offered.)