At Rula, we recommend that you review and update treatment plans every three months (at minimum) to ensure the treatment plan reflects the client’s presenting problem, current goals, and interventions to address the client's symptoms and treatment needs. Aside from guiding treatment, this is particularly important when considering the need for ongoing care and the medical necessity for services, as commercial payers require regular treatment plan updates in order to reimburse for therapy services. Therefore, treatment plans should be updated every three months, or more often as is clinically appropriate, based on the client's progress and therapeutic needs related to their condition.
You are required to complete an Initial Treatment Plan in the first session. You may select the drop-down option to "Determine treatment goals" in the initial assessment and then make updates during the next visit. The initial treatment plan will carry over to your future progress notes so that you can refer back to it as needed. Please refer to this Help Center Article to learn more about setting up an initial treatment plan.
At the three month mark (or sooner), you should review the treatment plan with your client and make updates as needed (this can be done quickly within the progress note template – see video below!). We recommend you document the date of review and goal updates within the “Focus of Session/Session Summary” section of the note (E.g. “Reviewed on 1/1/24 and updated treatment goals #2 and #3”). If the client is still working toward their initial goals, you can document “Reviewed on 1/1/24, all goals still relevant” in order to demonstrate that the plan was reviewed in session.
Updating Treatment Goals
Clients can have up to five active treatment goals at a time- enough to stay focused without feeling overwhelmed. If a client wants more than five active goals, this is a great opportunity to discuss prioritization and the benefits of smaller, manageable steps that sustain motivation and progress.
Goal Achieved
Celebrating a client’s progress is a meaningful milestone! When a treatment goal is achieved, document it in your latest progress note or a blank note, noting the completed goal, date, and any reflections on the journey. In the treatment plan section of the Portal, you can remove the goal by selecting the trash can icon.
Goal Requires Edits
When circumstances change, whether due to shifting focus, motivation, or resources, treatment goals may need to be revised. This should be a collaborative conversation with the client to determine the exact revisions that are required. Document the updated goal in a progress or blank note, including the revised language, start date, and reason for the change. In the Portal, you can either edit the existing goal or delete and replace it with a new one- both approaches work.
Goal Requires Discontinuation
If a goal is no longer relevant, it can be deleted using the trash can icon, with documentation in the progress note or blank note explaining why it was discontinued.
Video Demonstration
Note: We're now Rula! You may still hear Path in our videos from time to time and we appreciate your patience while we continue to update our content to align with our new name. Additionally, this video only applies to telehealth and not in-person appointments.
If you would like to learn some more tips on how to write quality, compliant treatment plans, please view the below video.