Treatment Plans

How We Structure Treatment Plans

There is no single “correct” way to write a treatment plan. Every agency, private practice, electronic health record (EHR), and insurance provider may have different documentation requirements or preferred formats. The structure presented throughout this guide reflects the format I have found to be both clinically effective and easy to follow. While wording and organization may vary across settings, most quality treatment plans contain the same core elements.

Core Elements

Diagnosis The patient’s clinical diagnosis, including the appropriate DSM diagnosis and corresponding ICD/F-code when applicable, which serves as the foundation for treatment planning.

Presenting Problem A brief description of the primary symptoms, concerns, or functional impairments that brought the patient to treatment.

Goals & Objectives Broad treatment goals are paired with specific, measurable objectives that allow progress to be monitored over time.

Interventions The therapeutic approaches, techniques, and clinician actions that will be used to help the patient achieve treatment goals. Examples include Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), Motivational Interviewing (MI), Solution-Focused Brief Therapy (SFBT), psychoeducation, mindfulness-based interventions, and skills training.

Timeline The anticipated frequency of treatment (for example, weekly or biweekly sessions) along with the timeframe for reviewing and updating the treatment plan, which is commonly every 90 days depending on agency and insurance requirements.

Sample Treatment Plan

Sample Treatment Plan – Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation

Diagnosis

Diagnosis: F90.2 – Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation

Presenting Problem

Patient presents with symptoms of inattention, hyperactivity, and impulsivity that interfere with daily functioning. Patient reports difficulty with maintaining focus, staying organized, following through with responsibilities, and managing impulsive responses. These symptoms contribute to increased stress, frustration, and decreased confidence in personal and professional functioning.

Goals & Objectives

Goal 1

Improve attention and organization to increase task follow through.

Patient Quote: “I want to be able to stay focused and actually finish what I start.”

Objective

Over the next 90 days, patient will begin to implement executive functioning strategies, including task prioritization, organization tools, and task breakdown methods, as evidenced by improved scores on the Adult ADHD Self Report Scale (ASRS).

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Goal 2

Improve emotional regulation and impulse control.

Patient Quote: “I want to stop reacting before I think things through.”

Objective

Over the next 90 days, patient will begin to practice coping skills, including cognitive reframing, mindfulness, and distress tolerance strategies, as evidenced by clinician observation of increased use of emotional regulation skills during sessions.

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Goal 3

Increase self confidence and reduce negative self perceptions related to ADHD symptoms.

Patient Quote: “I want to stop feeling like I’m always behind everyone else.”

Objective

Over the next 90 days, patient will begin to identify and challenge negative self-beliefs through cognitive restructuring and strengths-based interventions, as evidenced by patient self report of improved confidence and self-perception.

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Interventions

Cognitive Behavioral Therapy (CBT) Psychoeducation regarding ADHD symptoms and executive functioning Executive functioning skills training Mindfulness-based interventions Behavioral strategies to support organization and routine development Solution-Focused Brief Therapy (SFBT) Motivational Interviewing (MI) Strengths-based interventions

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Timeline

Session Frequency: Weekly individual therapy sessions.

Treatment Plan Review: Treatment plan will be reviewed and updated over the next 90 days, or sooner if clinically indicated.

This is what it would look like inside an EHR!