UTHCPC Procedures - Master Treatment Planning/Review Process

Master Treatment Planning/Review Process

Introduction
Date of Last Review: 1/12
SME: Chief Nurse Officer/ Medical Director/ Director of Social Services

UTHCPC adopted the Master Treatment Plan (MTP) to ensure that each patient has a comprehensive, age-specific, individualized plan for treatment that addresses his/her biological, psychological, educational, social, cultural, and developmental needs and choices.

Cover sheet

The multidisciplinary treatment team is responsible for reviewing the cover sheet. The patient/guardian/parent of a minor (under the age of 16) signs the Master Treatment Plan Cover Sheet. (If the patient is unable to review the cover sheet during multidisciplinary rounds, the RN follows up with the patient.) The Social Worker follows up with the guardian, if indicated, for review/ signature on the cover sheet.

Multidisciplinary Problem Aggregate (MPA) Content

Primary Language

1.0 The patient's primary language is identified/documented. The patient's need for a translator to facilitate communication is identified, if needed.

Positive Assessment Findings

1.0 The Multidisciplinary Problem Aggregate (MPA), as well as the Initial Psychiatric Examination (IPE), contains a listing of positive triggers gathered from the discipline-specific assessments as follows:

Members of the multidisciplinary team enter the positive triggers that correspond to the assessment document on the Multidisciplinary Problem Aggregate (MPA) within 24-72 hours of admission. The MPA entries may contain some historical data.

The plan of care and treatments is based on the patient's assets and strssors as identified in the assessment. All disciplines enter asset(s)/stressors, as appropriate for consideration in developing the patient's treatment plan.

Master Treatment Plan (MTP)
The Master Treatment Plan (MTP) identifies individualized problem(s), goals/objectives, and interventions. The MTP is completed within 3 days of admission.

Step

Process

Action

Problem(s)
and
Formulation

The problem list reflects an individual's mental, emotional and physical health needs.
The physician, in collaboration with other disciplines, evaluates and aggregates information captured on the MPA to formulate clinical impressions through the creation of a MTP Problem(s).
After problem(s) have been identified and prioritized by the attending physician, the team members develop the MTP.

Goal(s)

Goals for each problem are stated in measurable, behavioral terms (e.g., eliminate, diminish, etc.) that are based on an established timeframe (e.g., by the third day after admission). The individual disciplines enter the goal(s) that the individual patient should achieve. Goals identify long-range plans and objectives are short-term achievements.

Intervention

Interventions are planned actions designed by staff to meet behavioral changes identified as goals. Interventions include the frequency and the discipline responsible for carrying out the intervention(s).

MTP Review

Formal Master Treatment Plan (MTP) reviews are conducted no longer than 7 days after initiation of the plan, and every seven days thereafter. The MTP will also be updated to address the individual needs of the patient as his/her acuity or condition changes. Formal reviews will be started on a new document in the EMR for easy access and reference. The treatment plan review process examines the patient's progress in relation to goal attainment and timeframes. Additions, deletions or revisions of goals and interventions may be warranted. The patient/family participates in the process as appropriate.

Internal reviews may occur as clinically indicated.

MTP Review Process for Subacute Units- The weekly MTP review will be documented on the Subacute Unit Weekly Summary.

Related standards

The Joint Commission: Provision of Care, Treatment, and Services.

If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.