SOP 508.21-att-3: Attachment 3 - Comprehensive Treatment Plan Review Form (M50-01-03)

Division:
Mental Health Services
Effective Date:
September 23, 2020
Topic Area:
508 Policy - MH Evaluations/Screenings/Treatment
PowerDMS:
View on PowerDMS
Length:
138 words

Summary

This form documents the comprehensive review of an inmate's mental health treatment plan, including current diagnoses, level of care assessment, and progress toward treatment goals. It is used by mental health professionals (psychologists, psychiatrists, and APRNs) to evaluate whether the current level of care is appropriate and to justify any recommended changes. The form must be signed by the offender, service provider, psychologist, and psychiatrist/APRN, and is retained in the offender's mental health file for 10 years after completion of mental health services or sentence completion.

Key Topics

  • Comprehensive treatment plan
  • mental health treatment
  • level of care
  • utilization review
  • diagnoses
  • treatment goals
  • mental health assessment
  • inmate mental health
  • psychologist evaluation
  • psychiatrist evaluation
  • treatment plan review
  • mental health file

Full Text

SOP 508.21
Attachment 3

9/23/20

Principal Diagnosis: ________________________________________________________________________________

Other Diagnoses: __________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

General medical condition(s) relevant to mental disorder: ________________________________________________
______________________________________________________________________________________________
Utilization Review:

- Current Level of Care: [ ] Level 2 [ ] Level 3 [ ] Level 4

- Recommended Level of Care: [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Level 4

- Justification: ______________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________
__________________________________________________________________________________________
Summary of Progress and Changes in Goals, Interventions and Level of Care justification:

Due Date of Next Review: _____________

__________________________________ _____________ ____________ __________________________________
Offender Signature GDC ID# Date Printed/Typed Name

___________________________________________ ____________ _______________________________________
Primary Service Provider Signature Date Printed/Typed Name

________________________________________________ _____________ ___________________________________________
Psychologist Signature Date Printed/Typed Name

________________________________________________ _____________ ____________________________________________
Psychiatrist / APRN Signature Date Printed/Typed Name

Form no. M50-01-03 Page 1 of 1

Retention Schedule: Upon completion, this form shall be placed in the offender’s mental health file (section 2). At the end of the offender’s need for mental health
services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

Attachments (3)

  1. Initial Treatment Plan (262 words)
  2. Comprehensive Treatment Plan (M50-01-02) (340 words)
  3. Attachment 3 - Comprehensive Treatment Plan Review Form (M50-01-03) (138 words)
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