Treatment Planning Worksheet

I was at my second clinical affiliation this summer and I thought that I was doing an awesome job. During my fourth week in, my supervisor went on vacation for a week and a half and I was handling a full caseload by myself. My professor was coming in the following week and I convinced myself not to be nervous.... I was such a fool.

Basically, my professor pointed out that all I was doing was following orders. And that I did not go to school for $40K/year to follow someone else's treatment plans. My job was to assess and guide treatment based on patient presentation and my knowledge. The key thing that I got out of that painful experience was that... a treatment planning worksheet was in order!

See my treatment planning worksheet.

Name: ________      Week: ___________ of ______________    Discharge Date:___________

IMPAIRMENT/FUNCTIONAL LIMITATION	GOAL	INTERVENTION	REASONING

***Please note my disclaimer - this is my modification of the tx planning worksheet presented by my professor. This is NOT the only one. This is NOT the best one but the one that worked best for me during my second clinical rotation.

Here is my reasoning:
- Impairment/functional limitation column reminds us of patient presentation and to tease out the problems that is within our scope of practice to identify.
- Goal column reminds us what we are working towards.
- Intervention column- includes patient position, therapist hand placement and technique if you want to get fancy. More details, the better. It means you thought it through.
- Rationale column is a reminder that you should be doing the activity for a reason. I know this sounds like a "no-doh" but you see how quickly you get into the habit of "ambulating" with a patient as a form of therapeutic exercise.  In this column, you should consider the stages of motor control (mobility > stability > controlled mobility > skill) and how you are sequencing your interventions. Have you reduced the pain & inflammation so patient can do the full range of motion without squirming? Does the patient have the ROM... to do the motion? Does the patient have the core stability to maintain their trunk while doing the functional activity?
- Week x of x is to meant for the prognosis and present week. If you said that the patient will be able to complete their goals in 4 weeks and you notice that you are on week 3 of 4, you better be 1 week away from completing those goals! Its really a reminder to re-assess as you go along your treatment to make sure you are on track.
- Discharge date is a reminder of when you stated that patient will reach his/her goals.

You can add more columns but I like the four columns because its manageable. I feel like I can do this on the train or when I come home after an exhausting day at work. I fit this on a regular piece of blank paper - landscape orientation, .24" margins. I'm technologically backward otherwise I would post the file!

Often times, it was easy to do what I was told. But my professor was right when she said...but that's not what I went to school for. The treatment planning sheet helps guide you to progress a patient to meet their goals... which makes sense... doh, that's my job!

Picture from SILive.com and Simpsoncrazy.com.