Session Information

Client: CAREY, GRETTA (******) 3/22/1984

Staff: Roberts, Reno (IRN011)

Document Date: 6/17/2021

Client Program: (Not Set)

Treatment Plan

Primary Clinician Label: Roberts, Reno (IRN011)

Plan Type: Annual (Yearly)

Begin Date: 6/17/2021

End Date: 6/17/2022

Related MICP: All MICPs are displayed as Start Date - MICP Type - Agency Name

MICP Type:

Problem

Type:

Problem:

Problem Narrative: Gretta is a 37 year old, heterosexual, cisgender female. She presents via telehealth for annual BHA update. Client reports "the depression's better. The anxiety I still have a lot of that." Endorses anxiety attacks approx. once weekly aeb legs shaking and feeling "like the walls are closing in." She rates anxiety at 7/10. Client reports she wishes to continue med mgmt services only. She reports swelling, which she attributes to her psychiatric meds. Sub-Problem: N/A

Sub-Type: Active

Refer to External

Services?

N

External Referral

Comments:

Goal

Goal Narrative: Client hopes to "leave it behind me--all the drugs and stuff" and remain on medication management to "stay level."

Recovery/Resiliency/

Treatment Area:

Psychiatric

Target Date: 6/17/2022

Status: Ongoing

Completed Date:

Objective - APS

CAREY, GRETTA (390475) ABH Pavilion Outpatient Services - Treatment Plan Date Printed: 6/17/2021 3:54 PM

**This information is protected by

anyone. Any re-disclosure

Federal Regulation 42 C.F.R.

of this information by

1 of 3

and is illegal to re-release to

the recipient is prohibited**

Start Date: 6/17/2021

Objective Narrative: Gretta will demonstrate understanding/benefits of medication and how active participation in treatment helps him manage his anxiety AEB providing information about taking medications as prescribed, changes in behavior/mood/ health, & medication benefits/side effects over 3-6 months; and keeping all appointments.

Target Date: 6/17/2022

Status: Ongoing

Intervention #1: Nurse to assess client and follow prescriber orders for treatment effectiveness, & monitor symptoms/side-effects of medications prescribed. Service Class: Nursing Services (NRS)

Frequency: 1 - 4

Units Per: Quarterly

Intervention #2: Prescriber to assess and prescribe medications as needed; complete AIMS and mental status exam; order and review labs; monitor medication effectiveness; provide supportive counseling as needed.

Service Class: Psychiatric Treatment (PEM) (MICP 10120) Frequency: 1 - 4

Units Per: Quarterly

Objective - APS

Start Date: 6/17/2021

Objective Narrative: Gretta will acknowledge/demonstrate understanding of recovery model (client as driver of treatment) as evidenced by active participation in behavioral health assessment process and treatment plan development with staff to determine level of care needed and discuss treatment options/preferences for a successful recovery plan.

Target Date: 6/17/2022

Status: Ongoing

Intervention #1: Staff will provide ongoing assessment to identify treatment needs, goals & progress, as needed.

Service Class: Beh Health Assmt & Serv Plan Development (BHA) (MICP 10101) Frequency: 1 - 8

Units Per: Quarterly

Intervention #2: Prescriber, or appropriately credentialed staff, will assess client and make appropriate referrals to address treatment needs a minimum of yearly. Service Class: Diagnostic Assessment (DAS) (MICP 10103) Frequency: 1 - 4

Units Per: Quarterly

Signatures

Signatures:

Signatory:

Enter New Signatory: (if unavailable)

Signatures:

Signatory:

CAREY, GRETTA (390475) ABH Pavilion Outpatient Services - Treatment Plan Date Printed: 6/17/2021 3:54 PM

**This information is protected by

anyone. Any re-disclosure

Federal Regulation 42 C.F.R.

of this information by

2 of 3

and is illegal to re-release to

the recipient is prohibited**

Enter New Signatory: (if unavailable)

Signature #1: Reno J. Roberts (LMSW) - 6/17/2021 3:54 PM Signature History

Action Date Staff

Document Signed 6/17/2021 Reno J. Roberts

(LMSW)

CAREY, GRETTA (390475) ABH Pavilion Outpatient Services - Treatment Plan Date Printed: 6/17/2021 3:54 PM

**This information is protected by

anyone. Any re-disclosure

Federal Regulation 42 C.F.R.

of this information by

3 of 3

and is illegal to re-release to

the recipient is prohibited**

Contact this candidate