Md. Code Regs. 10.21.03.03

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.21.03.03 - Content and Nature of Individual Treatment Plan

A. The individual treatment plan is a comprehensive and thoughtfully written plan based on an initial diagnostic impression and an overall evaluation of the patient's specific needs and problems. It includes an inventory of the patient's strengths as well as weaknesses, and sets forth short-term measurable goals and behaviorally stated objectives aimed at maximal restoration of the patient's adaptive capacity and return to the community as soon as possible. Based on the above goals objectives, a plan of active treatment shall be prescribed which aims at the arrest, reversal, and amelioration of the patient's illness symptoms. There shall be included a long-range discharge goal as well as an estimate of the probable length of inpatient stay needed before transfer to a less restrictive or intensive treatment milieu.

B. The individual treatment plan shall be initially recorded and appropriately updated in the patient's permanent medical record.

C. The initial individual treatment plan shall be developed by members of the mental health professional treatment team who are directly involved in the patient's care including at least one member each from Regulation .02C(1) and (2), of this chapter. The initial individual treatment plan shall be signed by the physician responsible for its development. The names of the other members of the mental health professional treatment team involved in the development of the plan shall be noted adjacent to the signature of the physician.

D. A comprehensive, thoughtfully written, and properly signed individual treatment plan shall be recorded in the permanent medical record, or on a separate form which will become part of the permanent medical record, no later than 15 days after admission.

E. The individual treatment plan shall include or refer to essential written or verbal information which has been gathered, as well as relevant information derived from other parts of the medical record, that will help identify the specific needs and problems of the individual patient. The individual treatment plan shall also include an initial psychiatric diagnosis recorded in the official nomenclature of the American Psychiatric Association, discharge planning data relating to community and financial resources available to the patient, and the legal status of the patient. Information may not be gathered without the consent of the patient or of the patient's parent or legally appointed representative if the patient is a minor or is incompetent.

F. The individual treatment plan shall include a notation of any therapeutic task, labor, recreation, or other scheduled activity to be performed by the patient, including the rationale for these in relation to the treatment plan and the projected goals.

G. The individual treatment plan shall include, when applicable, a description of the patient's individualized educational plan. Special education plans, in conformance with the regulations of the Department of Education, are mandatory for patients through 20 years old.

H. The individual treatment plan shall include, when feasible, patient participation in accordance with Health-General Article, §10-706, Annotated Code of Maryland.

I. Care shall be taken to preserve the confidentiality of the patient-mental health professional treatment team member relationship. Information from a patient's record, including the individual treatment plan, may not be disclosed to any person, organization, or agency except in the case of a court order or with the written consent of the patient or of the patient's parent, if the patient is a minor, or legally appointed representative, if the patient is incompetent.

J. The individual treatment plan shall be periodically reassessed by members of the mental health professional treatment team who are working directly with the patient, including at least one member each from Regulation .02C(1) and (2), of this chapter, including the physician responsible for the implementation of the plan. This reassessment shall be made no less than once every 15 days for the first 2 months for all newly admitted or readmitted patients, and after that, at least once every 60 days.

K. The mental health professional treatment team members who make the reassessment shall place a written entry in the permanent medical record or on a separate form which will become part of the permanent medical record. This entry shall be signed by the physician responsible for the implementation of the plan. The names of the other members of the mental health professional treatment team involved in the reassessment of the plan shall be noted adjacent to the signature of the physician.

L. The initial individual treatment plan and all subsequent reassessments shall be easily identifiable as a separate, comprehensively written, and properly signed entry into the permanent medical record or on a separate form which will become part of the permanent medical record.

Md. Code Regs. 10.21.03.03