Treatment Plan Basics
This required element must be completed before beginning the treatment plan, and for clients ages 6+, it must be final‑saved.
What is the DLA-20?
These two screening tools must be updated during every treatment plan review to help inform level of care.
What are the DLA‑20 and PHQ‑A/PHQ‑4‑9?
Updates between reviews are permitted if this key condition is documented.
What is the documented clinical reasoning for the update?
If a client or guardian does not sign the plan, clinicians must document this and also ensure the client/guardian was offered this.
What is a copy of the treatment plan?
One frequent audit error is documenting interventions using this non‑committal verb instead of future‑tense action.
What is “may” instead of “will”?
A treatment plan is not active until this specific condition is met.
What is obtaining a licensed provider’s signature?
How often are treatment plan reviews required for non‑Medicare clients?
What is every 180 days?
When updating between reviews, staff must always default from this version of the plan.
What is the most recent treatment plan?
This assessment must be updated and referenced in the treatment plan review, and is required for Master’s‑level clinicians.
What is the Mental Status Exam (MSE)?
Plans often fail audit when clinicians do not update this foundational statement to reflect a change in focus.
What is the barrier/problem statement?
Only one of these should be marked “Add to Problem List,” since it becomes the basis for the problem/barrier statement.
What is the primary diagnosis?
During a review, clinicians must update and document progress on these three plan elements: the barrier statement, the goal, and these items.
What are the objectives?
This plan field must match the date of the day the update is made.
What is the Plan Date?
Objectives cannot remain unchanged longer than this period without modification.
What is 6 months?
Another common issue is failing to match the diagnosis in the plan to the most recent diagnosis in this location.
What is the prescriber’s note?
This section of the treatment plan must include both an intrinsic and extrinsic strength.
What are the client strengths?
This part of the review must reflect updated psychosocial, legal, risk, and medical factors since the last plan.
What is the Treatment Plan Review Template content?
These client‑initiated changes are valid reasons to update a plan mid‑cycle (name two).
What are: changing goals, adding or discontinuing services, or shifting treatment focus requiring new objectives?
Plans for children must document family involvement or provide this if involvement is contraindicated.
What is the rationale for why family involvement is not appropriate?
Audit notes indicate that missing these two required clinical forms creates discrepancies: one assessing mental status and one assessing safety.
What are the MSE and the Risk Assessment?
This part of the treatment plan must be written using what the client will do, must be measurable, and normally includes 1–3 items.
What are SMART objectives?
This major change was added to the treatment plan review template as of March 2025 and is required by BHA rules.
What are pregnancy & family planning screening questions?
During updates, clinicians must select this plan type to differentiate it from a review or annual update.
What is “Update”?
When clients are on the suicide care pathway, objectives and interventions must explicitly target this area.
What is suicidal and self‑harm behaviors?
Some clinicians fail to include interventions in the plan but mistakenly believe they belong only in reviews. What’s the correction?
Interventions must be included in the treatment plan, even if they are not reviewed in the treatment plan review.