Number - Compass Health

advertisement
Number
Problem
Altered Thoughts
Related to:
 history of mental illness
 biochemical imbalance
 medication
noncompliance
 sensory overload
 overwhelming
situational stressors
 recent traumatic event or
loss
As evidenced by:
 disturbed affect
 auditory hallucinations
 visual hallucinations
 tactile hallucinations
 paranoid delusions
 grandiose delusions
 somatic delusions
 religious preoccupation
 ideas of reference
 disorganized speech
 decreased concentration
 social withdrawal
 psychomotor
abnormalities
 other: ______________
___________________
 other: ______________
______________________
Date
ID
Goals and Objectives
Projected
Achieved
Date
Date
Actually
Achieved
Clinical Interventions
Approaches, Modality, Provider, & Frequency
Long-Term Goals:
 1. Patient will decrease acute, reactive, psychotic
symptoms and return to normal functioning in affect,
thinking, and relating.
 2. Other: ________________________________
___________________________________________
___________________________________________
1. Group Psychotherapy ____x/day, ___ days/week,
for one hour each. Therapist
2. Educational Group ____x/day, ____ days/week,
for one hour each. Nurse/ Therapist
3. Prescribe and adjust psychotropic meds. MD
Short-Term Goals/Objectives:

a. Patient will accept and understand that
distressing symptoms are due to mental
illness.

b. Patient will interact socially without fear or
suspicion being reported for 5consecutive
days.


c. Patient will think more clearly as
demonstrated by logical, coherent speech.
d. Patient will report a diminished or absence of
hallucinations/delusions for 5 consecutive
days.

e. Patient will verbalize strategies to decrease
anxiety associated with psychosis.

f. Patient will participate in therapeutic groups
to the best of his/her ability _______% of the
time.

g. Patient will verbalize need for medication
compliance and adhere to medication regime.

h. Other: ______________________________
__________________________________
__________________________________
4. Monitor patient’s response to psychotropic
medications ongoing. MD, Nurse
5. Educate patient about mental illness, the disease
process, symptom management & psychotropic
medications. Nurse
6. Build trust and establish therapeutic rapport
with patient. All staff
7. Monitor and record patients mood, behavior,
appetite, sleeping patterns, and medication
compliance. All staff
8. Other:
___________________________________________
___________________________________________
___________________________________________
Revised Goals/Objectives
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
MULTIDISCIPLINARY INTEGRATED TREATMENT PLAN
*Status Key Denotes: A=Achieved, D=Deferred, E=Extended, and R=Revised.
June 2006
Download