Diagnostic Summary
Outlines the current state and needs of the patient
What are the patient’s problems?
Where did the problems comes from?
What will be done about the problems?
The Problem List
Gives an update of the problems that Tim faces throughout the treatment process.
The problem list is generated based on the signs and symptoms reported by Tim.
Goals and Objectives
It is an outline of what Tim needs to do to restore himself to a normal functioning.
The goal outlined is the condition that is expected to change in Tim or in his family.
The goals should focus on better and more effective ways for Tim to cope.
Tim or his family should be the subject of the goals and objectives, and not the staff members.
For example: Tim will develop the necessary skills necessary to lead a sober and fulfilling life.
Developing Interventions
These are the steps directed towards achieving the stated objectives.
These are developed by observing the needs of the patient
May include any available treatment and any form of therapy applicable for Tim’s case.
The professional responsible for the intervention should be indicated too.
Evaluating Effectiveness of Treatment
Treatment is evaluated by keeping a record of the patient’s behavior, feelings, and thoughts.
Since thoughts and feelings are internal states, they are recorded by the patient. Behaviors, on the other hand, can be recorded by either the patient or the medical staff.
Review of Treatment Plan
Review is performed regularly throughout the patient’s treatment.
A review of the plan is necessary at points like admission, transfer, discharge, and a major occurrence in the patient’s health condition.
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