Mental Health Guides

Mental Health Guides, Tips, And Informations

Mental Health Nursing Care Plan

Mental Health Nursing Care Plan

Mental Health Nursing Care Plan


Mental health care plan is the document that contains the client’s mental health issues in detail as well as the framework of objectives and strategies that will help clients overcome mental health problems. To obtain the necessary information in order to complete the plan of care, the mental health field workers had to interview the clients. The information obtained when the interview is used to write a treatment plan.


Part 1 - Conduct A Mental Health Assessment

Collect information. Psychological evaluation is a fact gathering session that requires mental health field workers (counselors, therapists, social worker, psychologist, or psychiatrist) interviewing clients about psychological problems, a history of mental health problems, history families, and social issues in the past and the present in work, school, and relationships. Psychosocial evaluation can also examine specific substance abuse problems in the past or at present, as well as psychiatric drugs ever or the client being used.

  • Mental health workers can also consultated medical records and mental health clients during the process of evaluation. Make sure that the release of information (ROI document) the right has been signed.
  • Make sure you also explain the limits of confidentiality. Tell the client that you are talking about is confidential, unless the client has the intention of hurting yourself, others, or are aware of the existence of torture in the surrounding environment.
  • Prepare the evaluation of stopping if it seems clear the client is undergoing a crisis. For example, if the client has a desire to commit suicide or kill, you need to change the bow and follow the procedures of intervention immediately.

Follow parts of the evaluation. The majority of mental health facilities provide a template or form to be filled in by the workers when the interview. Examples of parts of the mental health assessment include (in chronological order):

  • The reason why reference (clients come to the place of treatment? How he referred to?) and behavioral symptoms (mood of depression, anxiety, appetite changes, sleep disturbances, etc.)
  • Problem history (When the problem started happening? How the intensity/frequency/duration issues? If there is, what efforts have been made to address the problem?)
  • Disturbances in the function of everyday life (problem with home, school, work, and relationships)
  • Psychological/psychiatric history (such as treatment or treatment in a hospital before, etc.)
  • Risk and current security issues (mind endangering themselves or others. If the patient is a fringe issue, stop the procedure immediately follow assessment and intervention of crisis.)
  • The issue of treatment, psychiatric, or medical (Indicate name of drug, dose levels, duration of client consumes the drug, and whether he used it according the recipe.)
  • History of the use of the substance and the current usage (the use or abuse of alcohol and other drugs.)
  • Family background (socio-economic level, the work of parents, parents ‘ marital Status (married/separated/divorced), cultural background, emotional/Medical History, family relationship)
  • Personal History
  • Infancy – developmental milestones, the frequency of contact with parents, potty training, and early medical history ( Early childhood and middle — adjustment at school, peer relationships, hobbies/activities/interests. Adolescence — the period of dating, reactions to puberty, the emergence of acting out behavior. Early and middle adulthood — career/job satisfaction, purpose of life, interpersonal relationships, marriage, economic stability, medical/emotional history, relationship with parents. Late adulthood — a medical history, a reaction to declining capabilities, economic stability )
  • Mental Status (Tidiness and cleanliness, the ability to talk, the mood, affection, etc.)
  • Other (self Concept (like/dislike), delighted most memory/most sad, fear, memory, dream stand out/returning)
  • Summary and clinical impressions (brief summary of client problems and symptoms should be written in narrative form. In this section, the counselor may include observations about the appearance and behavior of patients for evaluation.)
  • Diagnosis (use the information collected to form the corresponding DSM-V diagnosis or descriptive diagnosis.)
  • Recommendations (therapy, referral to psychiatrists, drug treatment, etc. This section should be guided by clinical diagnosis and impression. An effective treatment plan will lead to the return of the patient/client.)

Write down the observations of behavior. The counselor will assess mental status mini (MMSE) which includes the client’s appearance as well as observation of its interaction with the staff and other clients in the same building. The therapist will also make decisions about client’s mood (sad, angry, plain only), as well as affection (emotional display client, which can range from expansive, that shows a lot of emotion, until flat, that showed no emotion at all). These observations help counselors make diagnosis and write the appropriate treatment plan. Examples subject to mental status assessment highlighted include:

  • Tidiness and cleanliness (clean or rags)
  • Eye contact (Dodge, a little, no, or normal)
  • The activity of the motor (quiet, nervous, stiff, or fret)
  • Speech (soft, hard, depressed, stammering)
  • Style interaction (dramatic, sensitive, cooperative, ridiculous)
  • Orientation (if the client understands time, date, and circumstances that are experienced)
  • Intellectual functions (not disturbed, disturbed)
  • Memory (not disturbed, disturbed)
  • Mood (normal, unmood, crying, anxiety, depression)
  • Aphek (sensible, fickle, bluntly, flat)
  • Perceptual Disorders (hallucinations)
  • Impaired thought processes (concentration, judgment, insight)
  • Disorders of the contents of the mind (delusions, obsessions, thoughts of suicide)
  • Disorders of behavior (aggression, impulse control, demanding)


Make the diagnosis. The diagnosis is a major problem. Sometimes clients have multiple diagnoses such as Major Depressive Disorder and Alcohol Use. The entire diagnosis must be made before a treatment plan can be completed.

  • Diagnosis of selected based on the client’s symptoms and how the symptoms according to the criteria in the DSM. DSM is a diagnostic classification system created by the American Psychiatric Association (APA). Use the version of the Diagnostic and Statistical Manual (DSM-5) to search for the right diagnosis.
  • If you do not have a DSM-5, borrow from Your supervisor or colleagues. Don’t rely on online sources to make a proper diagnosis.
  • Use the main symptoms experienced by the client to conclude diagnosis.
  • If you are not sure about this diagnosis or need expert help, talk to your supervisor or clinical consult clinical experts experienced in.


Part 2 - Developing Purpose

Specify the goals might be accomplished. After completion of the initial assessment and make a diagnosis. You have to think about an intervention as well as the purpose for which you want to insert into the treatment. Generally, clients need help with goal setting, so it will help when you are preparing yourself before conduct discussions with the client.

  • For example, if your client has a Major Depressive Disorder, a goal that may reduce the symptoms of MDD is set.
  • Think about other destinations for the symptoms experienced by the client. Your client may have insomnia, depression, mood and weight gain recently (everything is a likely symptom of MDD). You can create separate objectives for each of this important issue.

Think about the intervention. This intervention is the principal changes in therapy. Therapeutic intervention you will trigger a change on your clients.

  • Specify the type of treatment or intervention that you might use, such as: scheduling activities, cognitive behavioral therapy and cognitive restructuring, conduct experiments, the giving of homework, as well as teaching the skills of coping problems such as relaxation techniques, mindfulness, and grounding.
  • Be sure to base on what you know. Part of being an ethical therapist is doing the appropriate competence so that you do not harm clients. Do not try the therapy that you don’t unless you got a hold of clinical supervision is tight from the experts.
  • If you are a beginner, try to use the appropriate workbook models or types of therapy that you choose. This can help you stay on track.

Discuss the objectives with the client. After the initial assessment is done, the therapist and the client will work together to make the appropriate treatment goal. This discussion needs to be done before a treatment plan is created.

  • Treatment plan should contain a direct input from the client. The counselor and the client decided together, the purpose of which will be listed in the treatment plan and strategy that will be used to achieve it.
  • Ask the client what he’d like to try in the treatment. He would probably say something like, “I want my depression is reduced.” Then, you can offer suggestions that might be useful for the purpose of reducing the symptoms of depresion (such as cognitive behavior therapy or CBT).
  • Try using the form which can be found on the internet for setting up goals. You can ask questions of the following on the client: One what purpose you have for this therapy? The difference in what you want to see? What steps can be taken to achieve this? Offer suggestions and ideas if clients are experiencing a deadlock. From the scale of zero to ten, zero means not reached at all and ten means achieved fully, how far your position in the scale is related to this purpose? This can help make your goals more measurable.

Create a concrete treatment goal. The goal of treatment is driving the success of therapy. This goal is also a major component of the plan of care. Try using the approach SMART goals:

  • Specific (specific) – set goals as clearly as possible, as it reduces the seriousness of depression, or reduce the frequency of night with insomnia.
  • Measurable (Measurable) – how do you know if you have achieved a goal? Make sure that this goal can be qualified, such as reducing depression scale of seriousness of 9/10 up to 6/10. Another example: reducing insomnia than three times per week to once a week.
  • Achievable (Achievable) – make sure your goals can be achieved and not too pompous. For example, reducing insomnia than seven nights per week until lost at all may be difficult to achieve in a short time. Consider converting it to four nights per week. Once you reach this goal, create new goals to eliminate insomnia.
  • Realistic and Resourced (realistic and Sourced)-Whether this goal can be achieved with the resources you have? Are there any other resources you need to help you reach your goals? How do you access these sources?
  • Time-limited (Unbounded time) – Set time restrictions for each purpose such as three months or six months.
  • The fully formed will be written like this: clients will reduce insomnia from three nights per week until one night in three months.


Part 3 - Creating care plans

Write down the components of a treatment plan. Treatment plan contains objectives that have been assigned counselor and therapist. Many facilities have a template or form a treatment plan must be filled counselors. A portion of the form may require counselors check the box that describes the symptoms of the client. Basic care plan must have the following information:

  • Name of the client and diagnosis.
  • Long term goal (such as a client’s statement, “I want to cure my depression.”)
  • Short term goal (the client will decrease the level of seriousness of the depression of 8/10 up to 5/10 in six months). A good treatment plan at least has three goals.
  • Clinical intervention/service type (individual, group therapy, cognitive behavioral therapy, etc.)
  • Involvement of clients (clients that are willing to do activities like coming to a place of therapy once a week, completing tasks of therapy at home, and put into practice the skills learned in troubleshooting care)
  • The date and the signature of the therapist and client

Write down the goals. Your goals need to be set out as clearly and as brief as possible. Remember the SMART goals and plans for every purpose so specific, measurable, achievable, realistic, and unbounded time. This plan forms may require you to take note of each objective separately, along with the interventions that will be used for that purpose, then the client is willing to do that activity.

Write down the specific interventions that you will use. The counselor will list the approved maintenance strategy client. Form of therapy which will be used to achieve this goal can be written here, as an individual or family therapy, substance abuse treatment, and medication management.

Sign the treatment plan. Both parties i.e. the client and the Counselor must sign the treatment plan to demonstrate that the agreement about the focus of treatment has been achieved.

  • Make sure this is done immediately after you complete treatment plan. The date on the form should be accurate and surely you want to indicate that the client agrees with the objectives of the plan of care.
  • If you do not sign the treatment plan, insurance companies may not be willing to pay for the services provided.

Review and fix as needed. You are expected to complete goals and create new goals along with the progress of clients in treatment. Treatment plan should list upcoming dates that will be used to review the progress of the client. The decision to continue the current treatment plan or make changes will be done at that time. You may need to review the purpose of the client every week or month to see any progress. Ask questions like, “how many times you experience insomnia this week?” After the client’s goals are met, say only experienced insomnia once a week. You can switch to other destinations (may be lowered to zero times per week, or improving the overall quality of sleep.


Tips Treatment plan is a document that is constantly undergoing changes, based on client needs.


The things you need

-          Evaluation form or Template

-          Medical records and mental health/mental

-          Template or form a treatment plan


Tags: , , , , , , ,


Thanks for read our article for update information please subscriber our newslatter below

No Responses

Leave a Reply