Treatment Plan Review/Update (Psychotherapy)

Patient: [Patient name and identifiers]

Date of Review: [Today's date]

Review Interval: [Start date] to [End date] (Use last plan review date or plan initiation date as start.)

Clinician: [Clinician name, credentials, role]

Setting: [office / telehealth / other]

(Do not include detailed verbatim session content or psychotherapy process notes. When information for a section is not available, omit that section rather than inserting placeholder text, except for Medical Necessity Rationale which should always be included. Maintain consistent progress status terminology and parallel structure across all goal areas.)

Reason for Review

[Trigger for this review: routine interval review, goal completion or plateau, symptom or functional change, diagnostic revision, frequency change, discharge planning, etc.] (1–2 sentences. If no discrete trigger, document as routine interval review.)

Current Diagnoses

• [Primary diagnosis with DSM/ICD code] (Mark as new, resolved, or changed since last review if applicable.)
• [Additional active diagnoses with DSM/ICD codes] (Include only those addressed by psychotherapy.)

(If diagnoses are unchanged, a single line stating diagnoses unchanged with the primary diagnosis listed is sufficient.)

Clinical Status Since Last Review

Symptom Course: [improving / worsening / fluctuating / stable] — [Brief description of clinically meaningful symptom changes relevant to treatment targets]

Functional Status: [Summary of functioning in relevant domains: work/school, relationships, sleep, ADLs] (Focus on changes since last review.)

Standardized Measures: [Tool name, most recent score(s), and trend] (Include only if measures were administered during this interval.)

Progress Toward Treatment Goals

(Order goal areas by clinical priority: safety-related first, then functional impairment, symptom/skill targets, and quality-of-life goals. Repeat the structured block below for each active goal area. Avoid detailed session-by-session content; focus on plan-level information.)

Goal Area [#]: [Problem/Focus Area]

Goal Statement: [Desired outcome in measurable/behavioral terms]

Current Objectives: [Specific objectives targeted this interval]

Interventions Delivered: [Therapeutic strategies applied, e.g., CBT techniques, skills training, exposure, behavioral activation] (Use concise, non-process language.)

Progress Status: [Met / Partially Met / In Progress / Not Met / Regressed / Discontinued] (If Discontinued, include reason.)

Evidence Supporting Status: [Patient report, observed behaviors, skill demonstration, functional gains, scale scores]

Barriers and Supports: [Factors impeding or facilitating progress]

Clinical Decision: [Continue unchanged / Revise objective or approach / Discontinue goal / Escalate care] (Specify the change if revising.)

(Add additional Goal Area sections as needed using the same structure.)

Updated Plan

[Summary of changes to goals, objectives, or interventions effective today] (If no changes, state that current goals and objectives continue as previously documented.)

• Treatment Approach: [Primary modality and focus, e.g., CBT, DBT, trauma-focused therapy]
• Homework/Skills Practice: [Assigned skills or practice between sessions]
• Care Coordination: [Referrals or communication with psychiatry, primary care, case management] (Include only if applicable.)
• Session Frequency: [Planned frequency and anticipated duration or number of sessions]
• Next Plan Review: [Target date or interval]

Medical Necessity Rationale

[Individualized rationale for continued psychotherapy addressing: active symptoms or maladaptive behaviors requiring skilled intervention; functional impairment targeted by treatment; reasonable expectation of improvement with continued treatment or deterioration if services withdrawn] (If progress has plateaued, explain rationale for continued care and changes being implemented. Link to documented goals and progress. 4–6 sentences. This section is required.)

Risk Assessment

(Include this section only when clinically indicated: suicidal ideation, self-harm, homicidal ideation, violence risk, grave disability, or abuse/neglect concerns are present or were assessed. Omit if risk concerns are not present and not a focus of treatment.)

Current Risk Level: [Low / Moderate / High] — [Clinical justification]

Protective Factors: [Protective factors identified]

Safety Planning: [Safety plan updates, means counseling, crisis resources reviewed]

Actions Taken: [Interventions, referrals, or level-of-care changes]

Discharge Planning

[Discharge criteria, anticipated timeline, relapse prevention or maintenance plan, follow-up arrangements, patient agreement or concerns] (Include only when discharge, step-down, or transfer is under active consideration. If discharge is not indicated, omit this section or state that discharge is not indicated at this time.)

Signature

Clinician Signature: [Electronic or handwritten per system]

Date/Time: [Date and time of signature]

Credentials: [Full credentials and role]

Co-signature/Supervision Attestation: [Supervising clinician name, credentials, attestation] (Include only when required for trainees.)