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Zhongwei Li
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skills/treatment-plans/README.md
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skills/treatment-plans/README.md
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# Treatment Plans Skill
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## Overview
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Skill for generating **concise, clinician-focused** medical treatment plans across all clinical specialties. Provides LaTeX/PDF templates with SMART goal frameworks, evidence-based interventions, regulatory compliance, and validation tools for patient-centered care planning.
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**Default to 1-page format** for most cases - think "quick reference card" not "comprehensive textbook".
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## What's Included
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### 📋 Seven Treatment Plan Types
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1. **One-Page Treatment Plan** (PREFERRED) - Concise, quick-reference format for most clinical scenarios
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2. **General Medical Treatment Plans** - Primary care, chronic diseases (diabetes, hypertension, heart failure)
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3. **Rehabilitation Treatment Plans** - Physical therapy, occupational therapy, cardiac/pulmonary rehab
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4. **Mental Health Treatment Plans** - Psychiatric care, depression, anxiety, PTSD, substance use
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5. **Chronic Disease Management Plans** - Complex multimorbidity, long-term care coordination
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6. **Perioperative Care Plans** - Preoperative optimization, ERAS protocols, postoperative recovery
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7. **Pain Management Plans** - Acute and chronic pain, multimodal analgesia, opioid-sparing strategies
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### 📚 Reference Files (5 comprehensive guides)
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- `treatment_plan_standards.md` - Professional standards, documentation requirements, legal considerations
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- `goal_setting_frameworks.md` - SMART goals, patient-centered outcomes, shared decision-making
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- `intervention_guidelines.md` - Evidence-based treatments, pharmacological and non-pharmacological
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- `regulatory_compliance.md` - HIPAA compliance, billing documentation, quality measures
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- `specialty_specific_guidelines.md` - Detailed guidelines for each treatment plan type
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### 📄 LaTeX Templates (7 professional templates)
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- `one_page_treatment_plan.tex` - **FIRST CHOICE** - Dense, scannable 1-page format (like precision oncology reports)
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- `general_medical_treatment_plan.tex` - Comprehensive medical care planning
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- `rehabilitation_treatment_plan.tex` - Functional restoration and therapy
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- `mental_health_treatment_plan.tex` - Psychiatric and behavioral health
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- `chronic_disease_management_plan.tex` - Long-term disease management
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- `perioperative_care_plan.tex` - Surgical and procedural care
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- `pain_management_plan.tex` - Multimodal pain treatment
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### 🔧 Validation Scripts (4 automation tools)
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- `generate_template.py` - Interactive template selection and generation
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- `validate_treatment_plan.py` - Comprehensive quality and compliance checking
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- `check_completeness.py` - Verify all required sections present
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- `timeline_generator.py` - Create visual treatment timelines and schedules
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## Quick Start
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### Generate a Treatment Plan Template
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```bash
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cd .claude/skills/treatment-plans/scripts
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python generate_template.py
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# Or specify type directly
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python generate_template.py --type general_medical --output diabetes_plan.tex
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```
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Available template types:
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- `one_page` (PREFERRED - use for most cases)
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- `general_medical`
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- `rehabilitation`
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- `mental_health`
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- `chronic_disease`
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- `perioperative`
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- `pain_management`
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### Compile to PDF
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```bash
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cd /path/to/your/treatment/plan
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pdflatex my_treatment_plan.tex
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```
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### Validate Your Treatment Plan
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```bash
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# Check for completeness
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python check_completeness.py my_treatment_plan.tex
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# Comprehensive validation
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python validate_treatment_plan.py my_treatment_plan.tex
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```
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### Generate Treatment Timeline
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```bash
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python timeline_generator.py --plan my_treatment_plan.tex --output timeline.pdf
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```
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## Standard Treatment Plan Components
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All templates include these essential sections:
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### 1. Patient Information (De-identified)
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- Demographics and relevant medical background
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- Active conditions and comorbidities
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- Current medications and allergies
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- Functional status baseline
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- HIPAA-compliant de-identification
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### 2. Diagnosis and Assessment Summary
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- Primary diagnosis (ICD-10 coded)
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- Secondary diagnoses
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- Severity classification
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- Functional limitations
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- Risk stratification
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### 3. Treatment Goals (SMART Format)
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**Short-term goals** (1-3 months):
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- Specific, measurable outcomes
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- Realistic targets with defined timeframes
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- Patient-centered priorities
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**Long-term goals** (6-12 months):
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- Disease control targets
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- Functional improvement objectives
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- Quality of life enhancement
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- Complication prevention
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### 4. Interventions
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- **Pharmacological**: Medications with dosages, frequencies, monitoring
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- **Non-pharmacological**: Lifestyle modifications, behavioral interventions, education
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- **Procedural**: Planned procedures, specialist referrals, diagnostic testing
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### 5. Timeline and Schedule
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- Treatment phases with timeframes
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- Appointment frequency
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- Milestone assessments
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- Expected treatment duration
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### 6. Monitoring Parameters
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- Clinical outcomes to track
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- Assessment tools and scales
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- Monitoring frequency
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- Intervention thresholds
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### 7. Expected Outcomes
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- Primary outcome measures
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- Success criteria
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- Timeline for improvement
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- Long-term prognosis
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### 8. Follow-up Plan
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- Scheduled appointments
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- Communication protocols
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- Emergency procedures
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- Transition planning
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### 9. Patient Education
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- Condition understanding
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- Self-management skills
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- Warning signs
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- Resources and support
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### 10. Risk Mitigation
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- Adverse effect management
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- Safety monitoring
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- Emergency action plans
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- Fall/infection prevention
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## Common Use Cases
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### 1. Type 2 Diabetes Management
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```
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Goal: Create comprehensive treatment plan for newly diagnosed diabetes
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Template: general_medical_treatment_plan.tex
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Key Components:
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- SMART goals: HbA1c <7% in 3 months, weight loss 10 lbs in 6 months
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- Medications: Metformin titration schedule
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- Lifestyle: Diet, exercise, glucose monitoring
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- Monitoring: HbA1c every 3 months, quarterly visits
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- Education: Diabetes self-management education
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```
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### 2. Post-Stroke Rehabilitation
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```
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Goal: Develop rehab plan for stroke patient with hemiparesis
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Template: rehabilitation_treatment_plan.tex
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Key Components:
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- Functional assessment: FIM scores, ROM, strength testing
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- PT goals: Ambulation 150 feet with cane in 12 weeks
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- OT goals: Independent ADLs, upper extremity function
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- Treatment schedule: PT/OT/SLP 3x week each
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- Home exercise program
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```
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### 3. Major Depressive Disorder
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```
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Goal: Create integrated treatment plan for depression
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Template: mental_health_treatment_plan.tex
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Key Components:
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- Assessment: PHQ-9 score 16 (moderate depression)
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- Goals: Reduce PHQ-9 to <5, return to work in 12 weeks
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- Psychotherapy: CBT weekly sessions
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- Medication: SSRI with titration schedule
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- Safety planning: Crisis contacts, warning signs
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```
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### 4. Total Knee Replacement
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```
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Goal: Perioperative care plan for elective TKA
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Template: perioperative_care_plan.tex
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Key Components:
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- Preop optimization: Medical clearance, medication management
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- ERAS protocol implementation
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- Postop milestones: Ambulation POD 1, discharge POD 2-3
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- Pain management: Multimodal analgesia
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- Rehab plan: PT starting POD 0
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```
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### 5. Chronic Low Back Pain
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```
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Goal: Multimodal pain management plan
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Template: pain_management_plan.tex
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Key Components:
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- Pain assessment: Location, intensity, functional impact
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- Goals: Reduce pain 7/10 to 3/10, return to work
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- Medications: Non-opioid analgesics, adjuvants
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- PT: Core strengthening, McKenzie exercises
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- Behavioral: CBT for pain, mindfulness
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- Interventional: Consider ESI if inadequate response
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```
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## SMART Goals Framework
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All treatment plans use SMART criteria for goal-setting:
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- **Specific**: Clear, well-defined outcome (not vague)
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- **Measurable**: Quantifiable metrics or observable behaviors
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- **Achievable**: Realistic given patient capabilities and resources
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- **Relevant**: Aligned with patient priorities and values
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- **Time-bound**: Specific timeframe for achievement
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### Examples
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**Good SMART Goals**:
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- Reduce HbA1c from 8.5% to <7% within 3 months
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- Walk independently 150 feet with assistive device by 8 weeks
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- Decrease PHQ-9 depression score from 18 to <10 in 8 weeks
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- Achieve knee flexion >90 degrees by postoperative day 14
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- Reduce pain from 7/10 to ≤4/10 within 6 weeks
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**Poor Goals** (not SMART):
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- "Feel better" (not specific or measurable)
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- "Improve diabetes" (not specific or time-bound)
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- "Get stronger" (not measurable)
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- "Return to normal" (vague, not specific)
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## Workflow Examples
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### Standard Treatment Plan Workflow
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1. **Assess patient** - Complete history, physical, diagnostic testing
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2. **Select template** - Choose appropriate template for clinical context
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3. **Generate template** - `python generate_template.py --type [type]`
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4. **Customize plan** - Fill in patient-specific information (de-identified)
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5. **Set SMART goals** - Define measurable short and long-term goals
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6. **Specify interventions** - Evidence-based pharmacological and non-pharmacological
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7. **Create timeline** - Schedule appointments, milestones, reassessments
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8. **Define monitoring** - Outcome measures, assessment frequency
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9. **Validate completeness** - `python check_completeness.py plan.tex`
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10. **Quality check** - `python validate_treatment_plan.py plan.tex`
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11. **Review quality checklist** - Compare to `quality_checklist.md`
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12. **Generate PDF** - `pdflatex plan.tex`
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13. **Review with patient** - Shared decision-making, confirm understanding
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14. **Implement and document** - Execute plan, track progress in clinical notes
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15. **Reassess and modify** - Adjust plan based on outcomes
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### Multidisciplinary Care Plan Workflow
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1. **Identify team members** - PCP, specialists, therapists, case manager
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2. **Create base plan** - Generate template for primary condition
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3. **Add specialty sections** - Integrate consultant recommendations
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4. **Coordinate goals** - Ensure alignment across disciplines
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5. **Define communication** - Team meeting schedule, documentation sharing
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6. **Assign responsibilities** - Clarify who manages each intervention
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7. **Create care timeline** - Coordinate appointments across providers
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8. **Share plan** - Distribute to all team members and patient
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9. **Track collectively** - Shared monitoring and outcome tracking
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10. **Regular team review** - Adjust plan collaboratively
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## Best Practices
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### Patient-Centered Care
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✓ Involve patients in goal-setting and decision-making
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✓ Respect cultural beliefs and language preferences
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✓ Address health literacy with appropriate language
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✓ Align plan with patient values and life circumstances
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✓ Support patient activation and self-management
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### Evidence-Based Practice
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✓ Follow current clinical practice guidelines
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✓ Use interventions with proven efficacy
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✓ Incorporate quality measures (HEDIS, CMS)
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✓ Avoid low-value or ineffective interventions
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✓ Update plans based on emerging evidence
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### Regulatory Compliance
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✓ De-identify per HIPAA Safe Harbor method (18 identifiers)
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✓ Document medical necessity for billing support
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✓ Include informed consent documentation
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✓ Sign and date all treatment plans
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✓ Maintain professional documentation standards
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### Quality Documentation
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✓ Complete all required sections
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✓ Use clear, professional medical language
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✓ Include specific, measurable goals
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✓ Specify exact medications (dose, route, frequency)
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✓ Define monitoring parameters and frequency
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✓ Address safety and risk mitigation
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### Care Coordination
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✓ Communicate plan to entire care team
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✓ Define roles and responsibilities
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✓ Coordinate across care settings
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✓ Integrate specialist recommendations
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✓ Plan for care transitions
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## Integration with Other Skills
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### Clinical Reports
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- **SOAP Notes**: Document treatment plan implementation and progress
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- **H&P Documents**: Initial assessment informs treatment planning
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- **Discharge Summaries**: Summarize treatment plan execution
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- **Progress Notes**: Track goal achievement and plan modifications
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### Scientific Writing
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- **Citation Management**: Reference clinical practice guidelines
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- **Literature Review**: Understand evidence base for interventions
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- **Research Lookup**: Find current treatment recommendations
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### Research
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- **Research Grants**: Treatment protocols for clinical trials
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- **Clinical Trial Reports**: Document trial interventions
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## Clinical Practice Guidelines
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Treatment plans should align with evidence-based guidelines:
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### General Medicine
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- American Diabetes Association (ADA) Standards of Care
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- ACC/AHA Cardiovascular Guidelines
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- GOLD COPD Guidelines
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- JNC-8 Hypertension Guidelines
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- KDIGO Chronic Kidney Disease Guidelines
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### Rehabilitation
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- APTA Physical Therapy Clinical Practice Guidelines
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- AOTA Occupational Therapy Practice Guidelines
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- AHA/AACVPR Cardiac Rehabilitation Guidelines
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- Stroke Rehabilitation Best Practices
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### Mental Health
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- APA (American Psychiatric Association) Practice Guidelines
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- VA/DoD Clinical Practice Guidelines for Mental Health
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- NICE Guidelines (UK)
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- Evidence-based psychotherapy protocols (CBT, DBT, ACT)
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### Pain Management
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- CDC Opioid Prescribing Guidelines
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- AAPM (American Academy of Pain Medicine) Guidelines
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- WHO Analgesic Ladder
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- Multimodal Analgesia Best Practices
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### Perioperative Care
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- ERAS (Enhanced Recovery After Surgery) Society Guidelines
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- ASA Perioperative Guidelines
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- SCIP (Surgical Care Improvement Project) Measures
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## Professional Standards
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### Documentation Requirements
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- Complete and accurate patient information
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- Clear diagnosis with appropriate ICD-10 coding
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- Evidence-based interventions
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- Measurable goals and outcomes
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- Defined monitoring and follow-up
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- Provider signature, credentials, and date
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### Medical Necessity
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Treatment plans must demonstrate:
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- Medical appropriateness of interventions
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- Alignment with diagnosis and severity
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- Evidence supporting treatment choices
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- Expected outcomes and benefit
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- Frequency and duration justification
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### Legal Considerations
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- Informed consent documentation
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- Patient understanding and agreement
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- Risk disclosure and mitigation
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- Professional liability protection
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- Compliance with state/federal regulations
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## Support and Resources
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### Getting Help
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1. **Check reference files** - Comprehensive guidance in `references/` directory
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2. **Review templates** - See example structures in `assets/` directory
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3. **Run validation scripts** - Identify issues with automated tools
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4. **Consult SKILL.md** - Detailed documentation and best practices
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5. **Review quality checklist** - Ensure all quality criteria met
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### External Resources
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- Clinical practice guidelines from specialty societies
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- UpToDate and DynaMed for treatment recommendations
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- AHRQ Effective Health Care Program
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- Cochrane Library for intervention evidence
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- CMS Quality Measures and HEDIS specifications
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- HEDIS (Healthcare Effectiveness Data and Information Set)
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### Professional Organizations
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- American Medical Association (AMA)
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- American Academy of Family Physicians (AAFP)
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- Specialty society guidelines (ADA, ACC, AHA, APA, etc.)
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- Joint Commission standards
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- Centers for Medicare & Medicaid Services (CMS)
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## Frequently Asked Questions
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### How do I choose the right template?
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Match the template to your primary clinical focus:
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- **Chronic medical conditions** → general_medical or chronic_disease
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- **Post-surgery or injury** → rehabilitation or perioperative
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- **Psychiatric conditions** → mental_health
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- **Pain as primary issue** → pain_management
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### What if my patient has multiple conditions?
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Use the `chronic_disease_management_plan.tex` template for complex multimorbidity, or choose the template for the primary condition and add sections for comorbidities.
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### How often should treatment plans be updated?
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- **Initial creation**: At diagnosis or treatment initiation
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- **Regular updates**: Every 3-6 months for chronic conditions
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- **Significant changes**: When goals are met or treatment is modified
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- **Annual review**: Minimum for all chronic disease plans
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### Can I modify the LaTeX templates?
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Yes! Templates are designed to be customized. Modify sections, add specialty-specific content, or adjust formatting to meet your needs.
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### How do I ensure HIPAA compliance?
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- Remove all 18 HIPAA identifiers (see Safe Harbor method)
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- Use age ranges instead of exact ages (e.g., "60-65" not "63")
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- Remove specific dates, use relative timelines
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- Omit geographic identifiers smaller than state
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- Use `check_deidentification.py` script from clinical-reports skill
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### What if validation scripts find issues?
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Review the specific issues identified, consult reference files for guidance, and revise the plan accordingly. Common issues include:
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- Missing required sections
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- Goals not meeting SMART criteria
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- Insufficient monitoring parameters
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- Incomplete medication information
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## License
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Part of the Claude Scientific Writer project. See main LICENSE file.
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||||
---
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For detailed documentation, see `SKILL.md`. For issues or questions, consult the comprehensive reference files in the `references/` directory.
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1573
skills/treatment-plans/SKILL.md
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1573
skills/treatment-plans/SKILL.md
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File diff suppressed because it is too large
Load Diff
185
skills/treatment-plans/assets/STYLING_QUICK_REFERENCE.md
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185
skills/treatment-plans/assets/STYLING_QUICK_REFERENCE.md
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@@ -0,0 +1,185 @@
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# Professional Treatment Plan Styling - Quick Reference
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## File Location
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`medical_treatment_plan.sty` - Available in the assets directory
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## Quick Start
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||||
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||||
```latex
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% !TEX program = xelatex
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\documentclass[11pt,letterpaper]{article}
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\usepackage{medical_treatment_plan}
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\usepackage{natbib}
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||||
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||||
\begin{document}
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||||
\maketitle
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||||
% Your content
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||||
\end{document}
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||||
```
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||||
## Custom Box Environments
|
||||
|
||||
### 1. Info Box (Blue) - General Information
|
||||
```latex
|
||||
\begin{infobox}[Title]
|
||||
Content
|
||||
\end{infobox}
|
||||
```
|
||||
**Use for:** Clinical assessments, monitoring schedules, titration protocols
|
||||
|
||||
### 2. Warning Box (Yellow/Red) - Critical Alerts
|
||||
```latex
|
||||
\begin{warningbox}[Title]
|
||||
Critical information
|
||||
\end{warningbox}
|
||||
```
|
||||
**Use for:** Safety protocols, decision points, contraindications
|
||||
|
||||
### 3. Goal Box (Green) - Treatment Goals
|
||||
```latex
|
||||
\begin{goalbox}[Title]
|
||||
Goals and targets
|
||||
\end{goalbox}
|
||||
```
|
||||
**Use for:** SMART goals, target outcomes, success metrics
|
||||
|
||||
### 4. Key Points Box (Light Blue) - Highlights
|
||||
```latex
|
||||
\begin{keybox}[Title]
|
||||
Important highlights
|
||||
\end{keybox}
|
||||
```
|
||||
**Use for:** Executive summaries, key takeaways, essential recommendations
|
||||
|
||||
### 5. Emergency Box (Red) - Emergency Info
|
||||
```latex
|
||||
\begin{emergencybox}
|
||||
Emergency contacts
|
||||
\end{emergencybox}
|
||||
```
|
||||
**Use for:** Emergency contacts, urgent protocols
|
||||
|
||||
### 6. Patient Info Box (White/Blue) - Demographics
|
||||
```latex
|
||||
\begin{patientinfo}
|
||||
Patient information
|
||||
\end{patientinfo}
|
||||
```
|
||||
**Use for:** Patient demographics and baseline data
|
||||
|
||||
## Professional Tables
|
||||
|
||||
```latex
|
||||
\begin{medtable}{Caption}
|
||||
\begin{tabular}{|l|l|l|}
|
||||
\hline
|
||||
\tableheadercolor
|
||||
\textcolor{white}{\textbf{Header 1}} & \textcolor{white}{\textbf{Header 2}} \\
|
||||
\hline
|
||||
Data row 1 \\
|
||||
\hline
|
||||
\tablerowcolor % Alternating gray
|
||||
Data row 2 \\
|
||||
\hline
|
||||
\end{tabular}
|
||||
\caption{Table caption}
|
||||
\end{medtable}
|
||||
```
|
||||
|
||||
## Color Scheme
|
||||
|
||||
- **Primary Blue** (0, 102, 153): Headers, titles
|
||||
- **Secondary Blue** (102, 178, 204): Light backgrounds
|
||||
- **Accent Blue** (0, 153, 204): Links, highlights
|
||||
- **Success Green** (0, 153, 76): Goals
|
||||
- **Warning Red** (204, 0, 0): Warnings
|
||||
|
||||
## Compilation
|
||||
|
||||
```bash
|
||||
xelatex document.tex
|
||||
bibtex document
|
||||
xelatex document.tex
|
||||
xelatex document.tex
|
||||
```
|
||||
|
||||
## Best Practices
|
||||
|
||||
1. **Match box type to purpose:** Green for goals, red/yellow for warnings
|
||||
2. **Don't overuse boxes:** Reserve for important information only
|
||||
3. **Maintain color consistency:** Stick to the defined scheme
|
||||
4. **Use white space:** Add `\vspace{0.5cm}` between major sections
|
||||
5. **Table alternating rows:** Use `\tablerowcolor` for readability
|
||||
|
||||
## Installation
|
||||
|
||||
**Option 1:** Copy `assets/medical_treatment_plan.sty` to your document directory
|
||||
|
||||
**Option 2:** Install to user TeX directory
|
||||
```bash
|
||||
mkdir -p ~/texmf/tex/latex/medical_treatment_plan
|
||||
cp assets/medical_treatment_plan.sty ~/texmf/tex/latex/medical_treatment_plan/
|
||||
texhash ~/texmf
|
||||
```
|
||||
|
||||
## Required Packages
|
||||
All automatically loaded by the style:
|
||||
- tcolorbox, tikz, xcolor
|
||||
- fancyhdr, titlesec, enumitem
|
||||
- booktabs, longtable, array, colortbl
|
||||
- hyperref, natbib, fontspec
|
||||
|
||||
## Example Structure
|
||||
|
||||
```latex
|
||||
\maketitle
|
||||
|
||||
\section*{Patient Information}
|
||||
\begin{patientinfo}
|
||||
Demographics
|
||||
\end{patientinfo}
|
||||
|
||||
\section{Executive Summary}
|
||||
\begin{keybox}[Plan Overview]
|
||||
Key highlights
|
||||
\end{keybox}
|
||||
|
||||
\section{Treatment Goals}
|
||||
\begin{goalbox}[SMART Goals]
|
||||
Goals list
|
||||
\end{goalbox}
|
||||
|
||||
\section{Medication Plan}
|
||||
\begin{infobox}[Dosing]
|
||||
Instructions
|
||||
\end{infobox}
|
||||
|
||||
\begin{warningbox}[Safety]
|
||||
Warnings
|
||||
\end{warningbox}
|
||||
|
||||
\section{Emergency}
|
||||
\begin{emergencybox}
|
||||
Contacts
|
||||
\end{emergencybox}
|
||||
```
|
||||
|
||||
## Troubleshooting
|
||||
|
||||
**Missing packages:**
|
||||
```bash
|
||||
sudo tlmgr install tcolorbox tikz pgf
|
||||
```
|
||||
|
||||
**Special characters not showing:**
|
||||
- Use XeLaTeX instead of PDFLaTeX
|
||||
- Or use LaTeX commands: `$\checkmark$`, `$\geq$`
|
||||
|
||||
**Header warnings:**
|
||||
- Already set to 22pt in style file
|
||||
- Adjust if needed
|
||||
|
||||
---
|
||||
|
||||
For complete documentation, see the "Professional Document Styling" section in SKILL.md
|
||||
|
||||
@@ -0,0 +1,665 @@
|
||||
% Chronic Disease Management Plan Template
|
||||
% For long-term management of multiple chronic conditions
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[11pt,letterpaper]{article}
|
||||
|
||||
% Packages
|
||||
\usepackage[top=1in,bottom=1in,left=1in,right=1in]{geometry}
|
||||
\usepackage{amsmath,amssymb}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{graphicx}
|
||||
\usepackage{array}
|
||||
\usepackage{longtable}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{lastpage}
|
||||
\usepackage{tabularx}
|
||||
\usepackage[most]{tcolorbox}
|
||||
|
||||
% Header and footer
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\lhead{Chronic Disease Management Plan}
|
||||
\rhead{Page \thepage\ of \pageref{LastPage}}
|
||||
\lfoot{Date Created: \today}
|
||||
\rfoot{Confidential Patient Information}
|
||||
|
||||
% Title formatting
|
||||
\usepackage{titlesec}
|
||||
\titleformat{\section}{\large\bfseries}{\thesection}{1em}{}
|
||||
\titleformat{\subsection}{\normalsize\bfseries}{\thesubsection}{1em}{}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% Title
|
||||
\begin{center}
|
||||
{\Large\bfseries CHRONIC DISEASE MANAGEMENT PLAN}\\[0.5em]
|
||||
{\large Comprehensive Long-Term Care Coordination}\\[0.5em]
|
||||
\rule{\textwidth}{1pt}
|
||||
\end{center}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== TREATMENT PLAN HIGHLIGHTS (Foundation Medicine Model) =====
|
||||
\begin{tcolorbox}[colback=orange!5!white,colframe=orange!75!black,title=\textbf{TREATMENT PLAN HIGHLIGHTS},fonttitle=\bfseries\large]
|
||||
|
||||
\textbf{Key Diagnoses:} [Primary chronic conditions - e.g., Type 2 Diabetes, CHF (NYHA II), CKD Stage 3]
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Primary Treatment Goals:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item [Goal 1 - e.g., Maintain HbA1c $<$7.5\% and prevent diabetic complications]
|
||||
\item [Goal 2 - e.g., Optimize heart failure management, prevent hospitalizations]
|
||||
\item [Goal 3 - e.g., Slow CKD progression, maintain eGFR $>$45 mL/min]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Main Interventions:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Medications:} [Core regimen - e.g., Metformin, Lisinopril, Furosemide, statin therapy]
|
||||
\item \textit{Lifestyle:} [Key modifications - e.g., Low-sodium diet, fluid restriction, regular exercise]
|
||||
\item \textit{Monitoring:} [Essential tracking - e.g., Daily weights, BP, glucose; quarterly labs]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Timeline:} [Care model - e.g., Monthly visits initially, then quarterly; annual comprehensive review]
|
||||
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== SECTION 1: PATIENT INFORMATION =====
|
||||
\section*{1. Patient Information and Problem List}
|
||||
|
||||
\textbf{HIPAA Notice}: De-identify all protected health information before sharing.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Patient ID} & [De-identified code, e.g., CDM-001] \\ \hline
|
||||
\textbf{Age Range} & [e.g., 60-65 years] \\ \hline
|
||||
\textbf{Sex} & [Male/Female/Other] \\ \hline
|
||||
\textbf{Date of Plan} & [Month/Year only] \\ \hline
|
||||
\textbf{Primary Care Provider} & [Name, MD/DO, Credentials] \\ \hline
|
||||
\textbf{Care Coordinator} & [Name, RN/NP/PA, if applicable] \\ \hline
|
||||
\textbf{Facility/System} & [Healthcare organization] \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\subsection*{Active Problem List (Prioritized)}
|
||||
|
||||
\begin{longtable}{|c|p{4cm}|c|p{3cm}|p{3.5cm}|}
|
||||
\hline
|
||||
\textbf{\#} & \textbf{Condition} & \textbf{ICD-10} & \textbf{Status} & \textbf{Specialists} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{\#} & \textbf{Condition} & \textbf{ICD-10} & \textbf{Status} & \textbf{Specialists} \\ \hline
|
||||
\endhead
|
||||
1 & Type 2 Diabetes Mellitus & E11.65 & Suboptimal control (HbA1c 8.2\%) & Endocrinology \\ \hline
|
||||
2 & Chronic Heart Failure (HFrEF) & I50.22 & Stable, NYHA Class II & Cardiology \\ \hline
|
||||
3 & Chronic Kidney Disease Stage 3b & N18.31 & Stable, eGFR 38 & Nephrology (as needed) \\ \hline
|
||||
4 & Hypertension & I10 & Well-controlled on meds & PCP \\ \hline
|
||||
5 & Hyperlipidemia & E78.5 & On statin, LDL at goal & PCP \\ \hline
|
||||
6 & Obstructive Sleep Apnea & G47.33 & On CPAP, adherent & Sleep Medicine \\ \hline
|
||||
7 & Obesity & E66.9 & BMI 34, stable weight & PCP, Nutrition \\ \hline
|
||||
8 & Osteoarthritis, bilateral knees & M17.0 & Managed conservatively & Ortho (prn) \\ \hline
|
||||
[Add rows] & & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Current Medication List}
|
||||
|
||||
\textit{Reconciled as of [Date]. Total: [X] medications}
|
||||
|
||||
\begin{longtable}{|p{3cm}|p{2cm}|p{1.8cm}|p{3cm}|p{3.5cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Indication} & \textbf{Prescriber} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Indication} & \textbf{Prescriber} \\ \hline
|
||||
\endhead
|
||||
Metformin ER & 1000mg & BID & Diabetes & PCP \\ \hline
|
||||
Insulin glargine & 24 units & QHS & Diabetes & Endocrinology \\ \hline
|
||||
Carvedilol & 12.5mg & BID & Heart failure, HTN & Cardiology \\ \hline
|
||||
Lisinopril & 40mg & Daily & Heart failure, HTN, CKD protection & Cardiology \\ \hline
|
||||
Furosemide & 40mg & Daily & Heart failure (diuresis) & Cardiology \\ \hline
|
||||
Atorvastatin & 40mg & QHS & Hyperlipidemia, ASCVD prevention & PCP \\ \hline
|
||||
Aspirin & 81mg & Daily & ASCVD prevention & PCP \\ \hline
|
||||
[Continue list] & & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Care Team and Specialists}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Primary Care Provider}: [Name, practice] - Coordinates overall care
|
||||
\item \textbf{Cardiology}: [Name] - Heart failure management
|
||||
\item \textbf{Endocrinology}: [Name] - Diabetes optimization
|
||||
\item \textbf{Nephrology}: [Name if engaged] - CKD monitoring
|
||||
\item \textbf{Care Coordinator/Navigator}: [Name] - Appointment coordination, patient education
|
||||
\item \textbf{Pharmacist}: [Clinical pharmacist if available] - Medication reconciliation, optimization
|
||||
\item \textbf{Registered Dietitian}: [Name] - Medical nutrition therapy
|
||||
\item \textbf{Social Worker}: [Name if engaged] - Psychosocial support, resources
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 2: DISEASE-SPECIFIC ASSESSMENTS =====
|
||||
\section*{2. Disease-Specific Assessments and Status}
|
||||
|
||||
\subsection*{2.1 Type 2 Diabetes Mellitus}
|
||||
|
||||
\textbf{Current Status}: Suboptimal control
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{HbA1c}: 8.2\% (target $<$7\%)
|
||||
\item \textbf{Fasting Glucose}: Average 165 mg/dL (target 80-130)
|
||||
\item \textbf{Time in Range}: Approximately 55\% (target $>$70\%)
|
||||
\item \textbf{Hypoglycemia}: Infrequent, 1-2 episodes/month (BG 65-70)
|
||||
\item \textbf{Duration}: 12 years
|
||||
\item \textbf{Complications Screening}:
|
||||
\begin{itemize}
|
||||
\item Retinopathy: Mild NPDR, followed by ophthalmology
|
||||
\item Nephropathy: CKD stage 3b, urine ACR 180 mg/g (albuminuria)
|
||||
\item Neuropathy: Mild peripheral neuropathy, no foot ulcers
|
||||
\item Cardiovascular: History of heart failure
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.2 Chronic Heart Failure (HFrEF)}
|
||||
|
||||
\textbf{Current Status}: Stable, NYHA Class II
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Ejection Fraction}: 35\% (reduced, HFrEF)
|
||||
\item \textbf{Etiology}: Ischemic cardiomyopathy (prior MI 5 years ago)
|
||||
\item \textbf{NYHA Class}: II - Slight limitation, comfortable at rest, symptoms with ordinary activity
|
||||
\item \textbf{Symptoms}: Mild dyspnea on exertion, no orthopnea/PND, occasional LE edema
|
||||
\item \textbf{Weight}: Stable, patient monitors daily
|
||||
\item \textbf{GDMT Status}:
|
||||
\begin{itemize}
|
||||
\item ACE inhibitor: Lisinopril 40mg daily (at target dose)
|
||||
\item Beta-blocker: Carvedilol 12.5mg BID (target 25mg BID - limited by fatigue)
|
||||
\item Diuretic: Furosemide 40mg daily
|
||||
\item Need to consider: SGLT2 inhibitor (also beneficial for diabetes), ARNI
|
||||
\end{itemize}
|
||||
\item \textbf{Device Therapy}: No ICD/CRT currently, discussed with cardiology
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.3 Chronic Kidney Disease Stage 3b}
|
||||
|
||||
\textbf{Current Status}: Stable
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{eGFR}: 38 mL/min/1.73m² (Stage 3b, moderate-severe decrease)
|
||||
\item \textbf{Creatinine}: 1.8 mg/dL (stable)
|
||||
\item \textbf{Urine Albumin}: ACR 180 mg/g (albuminuria, from diabetes)
|
||||
\item \textbf{Etiology}: Diabetic nephropathy, hypertensive nephropathy
|
||||
\item \textbf{Progression Risk}: Moderate-high (diabetes, albuminuria)
|
||||
\item \textbf{Complications}: Anemia (Hgb 11.2), managed with iron supplementation
|
||||
\item \textbf{Renal Protection}: ACE inhibitor, BP control, glucose control, limit nephrotoxins
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.4 Additional Conditions Summary}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Hypertension}: Well-controlled, average home BP 128/78 mmHg
|
||||
\item \textbf{Hyperlipidemia}: LDL 65 mg/dL (at goal $<$70 for ASCVD), on statin
|
||||
\item \textbf{Obstructive Sleep Apnea}: On CPAP nightly, AHI reduced from 32 to 4, good adherence
|
||||
\item \textbf{Obesity}: BMI 34, weight stable, difficulty with weight loss due to HF exercise limitations
|
||||
\item \textbf{Osteoarthritis}: Bilateral knee pain, managed with acetaminophen, PT, avoid NSAIDs (CKD)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 3: INTEGRATED GOALS =====
|
||||
\section*{3. Integrated Treatment Goals (SMART Format)}
|
||||
|
||||
\subsection*{3.1 Short-Term Goals (3-6 months)}
|
||||
|
||||
\textbf{Diabetes Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item Reduce HbA1c from 8.2\% to $<$7.5\% within 3 months by optimizing insulin dosing and medication adherence.
|
||||
\item Improve fasting glucose to 100-140 mg/dL range through medication adjustment and dietary changes within 3 months.
|
||||
\item Complete annual diabetic eye exam and foot exam within 1 month.
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Heart Failure Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item Maintain NYHA Class II status (no worsening) with daily weight monitoring and adherence to fluid/sodium restrictions.
|
||||
\item Add SGLT2 inhibitor for dual diabetes and heart failure benefit within 1 month.
|
||||
\item Improve exercise tolerance: Walk 15 minutes daily without dyspnea within 3 months.
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{CKD Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item Maintain eGFR stability ($\pm$5 mL/min from baseline 38) over 6 months.
|
||||
\item Reduce urine albumin-to-creatinine ratio from 180 to $<$100 mg/g with BP and glucose control.
|
||||
\item Avoid nephrotoxic agents (NSAIDs, contrast without prophylaxis).
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Cross-Cutting Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item Medication adherence $>$90\% measured by refill rates and pill counts within 3 months.
|
||||
\item Weight loss of 5\% body weight (10 lbs) through diet modification within 6 months.
|
||||
\item Blood pressure maintenance at $<$130/80 mmHg (home average).
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.2 Long-Term Goals (6-12 months)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Diabetes}: Achieve HbA1c $<$7\% and prevent progression of microvascular complications.
|
||||
\item \textbf{Heart Failure}: Optimize GDMT, prevent hospitalizations, maintain functional status.
|
||||
\item \textbf{CKD}: Slow progression (goal: $<$2 mL/min/year eGFR decline), delay need for dialysis.
|
||||
\item \textbf{Quality of Life}: Maintain independence in ADLs, engage in meaningful activities (gardening, grandchildren visits).
|
||||
\item \textbf{Prevention}: Up-to-date with all preventive care (vaccinations, cancer screenings).
|
||||
\item \textbf{Coordination}: Seamless care transitions, all providers aware of care plan, no conflicting treatments.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.3 Patient-Centered Priorities}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Priority 1}: "I don't want to end up on dialysis like my brother"
|
||||
\item \textbf{Priority 2}: "I want to keep up with my grandkids"
|
||||
\item \textbf{Priority 3}: "I want to reduce my medications if possible" (pill burden concern)
|
||||
\item \textbf{Priority 4}: "I want to avoid being hospitalized again"
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 4: COMPREHENSIVE INTERVENTIONS =====
|
||||
\section*{4. Comprehensive Interventions}
|
||||
|
||||
\subsection*{4.1 Medication Management and Optimization}
|
||||
|
||||
\textbf{Current Regimen Optimization}:
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{ADD: Empagliflozin (Jardiance) 10mg daily}
|
||||
\begin{itemize}
|
||||
\item \textit{Rationale}: SGLT2 inhibitor provides dual benefit - improves diabetes control AND reduces HF hospitalizations/mortality (EMPEROR-Reduced trial). Also slows CKD progression.
|
||||
\item \textit{Monitoring}: eGFR (hold if $<$20), volume status, UTI symptoms, DKA risk (low in T2DM)
|
||||
\item \textit{Expected benefit}: HbA1c reduction 0.5-0.8\%, reduced HF events 25-30\%
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{TITRATE: Insulin glargine}
|
||||
\begin{itemize}
|
||||
\item \textit{Current}: 24 units QHS, fasting BG averaging 165
|
||||
\item \textit{Plan}: Increase by 2 units every 3 days until fasting BG 100-130, patient to self-titrate with daily phone/portal check-ins
|
||||
\item \textit{Expected dose}: Likely 30-36 units
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{OPTIMIZE: Beta-blocker (carvedilol)}
|
||||
\begin{itemize}
|
||||
\item \textit{Current}: 12.5mg BID (patient reports fatigue at higher doses)
|
||||
\item \textit{Plan}: Trial slow up-titration to 18.75mg BID, monitor for tolerance
|
||||
\item \textit{Goal}: Target dose 25mg BID for HFrEF mortality benefit
|
||||
\item \textit{Alternative}: Consider switching to different beta-blocker if intolerable
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{CONTINUE}: ACE inhibitor (lisinopril 40mg) - at target dose
|
||||
|
||||
\item \textbf{CONSIDER FUTURE}: Sacubitril/valsartan (Entresto) to replace lisinopril if HF symptoms progress
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Medication Safety}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Polypharmacy Review}: Current medication count [X], review quarterly for deprescribing opportunities
|
||||
\item \textbf{Renal Dosing}: All medications reviewed for CKD Stage 3b, adjust as needed
|
||||
\item \textbf{Drug Interactions}: Monitor K+ with ACE + diuretic, avoid NSAIDs (CKD, HF)
|
||||
\item \textbf{Adherence Support}: Pill organizer, medication list wallet card, automatic refills, pharmacy synchronization
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.2 Lifestyle and Self-Management Interventions}
|
||||
|
||||
\textbf{Dietary Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Diabetes}:
|
||||
\begin{itemize}
|
||||
\item Carbohydrate consistency: 45-60g per meal
|
||||
\item Mediterranean diet pattern
|
||||
\item Limit refined sugars and processed carbohydrates
|
||||
\end{itemize}
|
||||
\item \textbf{Heart Failure}:
|
||||
\begin{itemize}
|
||||
\item Sodium restriction: $<$2000mg daily (low-sodium products, avoid processed foods)
|
||||
\item Fluid restriction: 1.5-2L daily if needed for volume management
|
||||
\end{itemize}
|
||||
\item \textbf{CKD}:
|
||||
\begin{itemize}
|
||||
\item Moderate protein intake: 0.8-1.0 g/kg/day
|
||||
\item Phosphorus and potassium awareness (but not severely restricted at Stage 3b)
|
||||
\end{itemize}
|
||||
\item \textbf{Weight Loss}: 500 kcal/day deficit for gradual weight loss
|
||||
\item \textbf{Referral}: Registered dietitian for medical nutrition therapy
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Physical Activity}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Goal}: 150 min/week moderate activity (walking, swimming)
|
||||
\item \textbf{Heart Failure Considerations}: Start with 10-15 min sessions, gradually increase, monitor symptoms
|
||||
\item \textbf{Diabetes Benefits}: Improves insulin sensitivity, glucose control
|
||||
\item \textbf{Cardiac Rehabilitation}: Consider referral if not previously completed
|
||||
\item \textbf{Progression}: Track with pedometer/activity tracker, goal 7000-10,000 steps daily
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Self-Monitoring}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Daily}:
|
||||
\begin{itemize}
|
||||
\item Weight (same time, same scale) - report gain $>$2-3 lbs in 2 days
|
||||
\item Blood glucose: Fasting and pre-dinner
|
||||
\item Blood pressure: Morning and evening
|
||||
\end{itemize}
|
||||
\item \textbf{Weekly}:
|
||||
\begin{itemize}
|
||||
\item Symptom check (dyspnea, edema, chest pain, hypoglycemia frequency)
|
||||
\item Medication adherence review
|
||||
\end{itemize}
|
||||
\item \textbf{Recording}: Use logbook or smartphone app (MyChart, Apple Health)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Other Lifestyle Factors}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{CPAP Adherence}: Continue nightly use, download compliance data quarterly
|
||||
\item \textbf{Smoking}: [If applicable - cessation interventions]
|
||||
\item \textbf{Alcohol}: Limit to $\leq$1 drink/day (heart failure, diabetes management)
|
||||
\item \textbf{Stress Management}: Mindfulness, adequate sleep, social engagement
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.3 Disease-Specific Monitoring and Screening}
|
||||
|
||||
\textbf{Diabetes Monitoring}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item HbA1c every 3 months until at goal, then every 6 months
|
||||
\item Lipid panel annually
|
||||
\item Urine albumin-to-creatinine ratio annually
|
||||
\item Comprehensive foot exam every visit, monofilament testing annually
|
||||
\item Dilated eye exam annually (ophthalmology)
|
||||
\item Dental exam every 6 months (periodontal disease link)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Heart Failure Monitoring}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Daily weights, report significant changes
|
||||
\item BNP or NT-proBNP when symptoms change
|
||||
\item Echocardiogram annually or if clinical change
|
||||
\item EKG annually
|
||||
\item Functional assessment (6-minute walk test) periodically
|
||||
\end{itemize}
|
||||
|
||||
\textbf{CKD Monitoring}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item eGFR and creatinine every 3-6 months
|
||||
\item Urine ACR annually
|
||||
\item CBC (anemia), CMP (electrolytes, calcium, phosphorus) every 6 months
|
||||
\item Vitamin D, PTH if indicated
|
||||
\item Bone density scan (increased fracture risk)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Preventive Care}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Influenza vaccine annually
|
||||
\item Pneumococcal vaccines (PCV20 or PCV15+PPSV23) per ACIP guidelines
|
||||
\item COVID-19 vaccination per current recommendations
|
||||
\item Zoster vaccine (Shingrix)
|
||||
\item Colorectal cancer screening per age guidelines
|
||||
\item [Other age/sex-appropriate screenings]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 5: CARE COORDINATION =====
|
||||
\section*{5. Care Coordination and Communication}
|
||||
|
||||
\subsection*{Provider Communication Plan}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|X|}
|
||||
\hline
|
||||
\textbf{Provider} & \textbf{Visit Frequency} & \textbf{Communication/Coordination} \\ \hline
|
||||
Primary Care & Every 3 months & Care plan coordinator, medication reconciliation, preventive care \\ \hline
|
||||
Cardiology & Every 4-6 months & HF medication optimization, EF monitoring, device consideration \\ \hline
|
||||
Endocrinology & Every 3-4 months & Diabetes management, insulin titration, complications screening \\ \hline
|
||||
Nephrology & As needed (if eGFR $<$30 or rapid decline) & CKD management, dialysis planning if needed \\ \hline
|
||||
Dietitian & Monthly x3, then quarterly & Nutrition counseling, meal planning \\ \hline
|
||||
Pharmacist & Quarterly & Medication review, adherence counseling, cost optimization \\ \hline
|
||||
Care Coordinator & Monthly phone check-in & Appointment scheduling, barrier identification, education \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Information Sharing}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Shared EHR access for all providers in health system
|
||||
\item Medication reconciliation after each specialist visit
|
||||
\item Lab results shared via patient portal and provider notifications
|
||||
\item Care plan accessible to all team members
|
||||
\item Patient carries medication list and problem list
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Care Transitions Management}
|
||||
|
||||
\textbf{Hospital Discharge Protocol}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item PCP notified within 24 hours of admission and discharge
|
||||
\item Follow-up appointment within 7 days of discharge
|
||||
\item Medication reconciliation at discharge and first follow-up
|
||||
\item Red flags review: HF exacerbation signs, hyperglycemia, AKI
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Specialty Referral Coordination}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Care coordinator ensures specialist appointments scheduled
|
||||
\item Specialist notes reviewed by PCP within 1 week
|
||||
\item Treatment recommendations integrated into care plan
|
||||
\item Conflicting recommendations discussed among providers
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 6: MONITORING AND OUTCOMES =====
|
||||
\section*{6. Monitoring Parameters and Quality Measures}
|
||||
|
||||
\subsection*{Clinical Outcomes Dashboard}
|
||||
|
||||
\begin{longtable}{|p{3.5cm}|p{2.5cm}|p{2cm}|p{2cm}|p{3cm}|}
|
||||
\hline
|
||||
\textbf{Parameter} & \textbf{Baseline} & \textbf{Target} & \textbf{Current} & \textbf{Frequency} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Parameter} & \textbf{Baseline} & \textbf{Target} & \textbf{Current} & \textbf{Frequency} \\ \hline
|
||||
\endhead
|
||||
HbA1c & 8.2\% & $<$7\% & [update] & Q3-6 months \\ \hline
|
||||
Fasting Glucose & 165 mg/dL & 100-130 & [update] & Daily (patient), labs Q3mo \\ \hline
|
||||
Blood Pressure & 142/86 & $<$130/80 & [update] & Daily (patient), each visit \\ \hline
|
||||
LDL Cholesterol & 65 mg/dL & $<$70 & At goal & Annually \\ \hline
|
||||
eGFR & 38 mL/min & Stable ($\pm$5) & [update] & Every 3-6 months \\ \hline
|
||||
Urine ACR & 180 mg/g & $<$100 & [update] & Annually \\ \hline
|
||||
Weight & [baseline] lbs & -10 lbs (5\%) & [update] & Daily (patient), each visit \\ \hline
|
||||
BNP/NT-proBNP & [if available] & Stable & [update] & When symptomatic \\ \hline
|
||||
Ejection Fraction & 35\% & Monitor & [date of last echo] & Annually or if change \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Quality Measure Tracking (HEDIS/CMS)}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ✓ Diabetes HbA1c testing (every 6 months)
|
||||
\item ☐ Diabetes HbA1c control ($<$8\%) - \textit{Target: achieve}
|
||||
\item ✓ Diabetes eye exam (annual dilated)
|
||||
\item ☐ Diabetes medical attention for nephropathy (urine ACR) - \textit{Due [month]}
|
||||
\item ✓ Blood pressure control ($<$140/90 for diabetes)
|
||||
\item ✓ Statin therapy for ASCVD
|
||||
\item ✓ ACE/ARB therapy for diabetes with hypertension
|
||||
\item ✓ Beta-blocker for HFrEF
|
||||
\item ☐ Flu vaccine current year - \textit{Due [month]}
|
||||
\item ✓ Pneumococcal vaccine
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 7: PATIENT EDUCATION AND ACTIVATION =====
|
||||
\section*{7. Patient Education and Self-Management Support}
|
||||
|
||||
\subsection*{Disease Education Completed}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Diabetes}: Pathophysiology, complications, importance of glucose control, hypoglycemia recognition
|
||||
\item \textbf{Heart Failure}: How heart failure affects body, medication importance, fluid/sodium restrictions, warning signs
|
||||
\item \textbf{CKD}: Kidney function, progression risk, renal protection strategies, medication precautions
|
||||
\item \textbf{Medication Purposes}: Why each medication is prescribed, expected benefits
|
||||
\item \textbf{Lifestyle Impact}: How diet, exercise, weight loss benefit all conditions
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Self-Management Skills Training}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ✓ Blood glucose monitoring technique
|
||||
\item ✓ Insulin injection technique and storage
|
||||
\item ✓ Home blood pressure monitoring
|
||||
\item ✓ Daily weight tracking and interpretation
|
||||
\item ✓ Symptom recognition (HF exacerbation, hypoglycemia, hyperglycemia)
|
||||
\item ✓ Medication organization (pill box use)
|
||||
\item ☐ Dietary skills: Carb counting, label reading, low-sodium food selection
|
||||
\item ☐ Sick day management (when to call, medication adjustments)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Warning Signs - When to Call Provider}
|
||||
|
||||
\textbf{Call office same day or go to ED if}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Weight gain $>$2-3 lbs in 2 days or 5 lbs in 1 week (heart failure)
|
||||
\item Increased shortness of breath, cannot lie flat, new leg swelling
|
||||
\item Chest pain or pressure
|
||||
\item Blood glucose consistently $>$300 or $<$60 mg/dL
|
||||
\item Decreased urine output, dark urine, swelling
|
||||
\item Dizziness, lightheadedness, syncope
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Resources and Support}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Diabetes self-management education program (DSMES)
|
||||
\item Cardiac rehabilitation program
|
||||
\item Patient portal for lab results, messaging, educational materials
|
||||
\item American Diabetes Association (diabetes.org) resources
|
||||
\item American Heart Association (heart.org) HF information
|
||||
\item National Kidney Foundation (kidney.org) CKD education
|
||||
\item Local support groups [if available]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 8: CONTINGENCY PLANNING =====
|
||||
\section*{8. Contingency Planning and Risk Mitigation}
|
||||
|
||||
\subsection*{Hospital Readmission Prevention}
|
||||
|
||||
\textbf{High-Risk Period}: 30 days post-discharge
|
||||
|
||||
\textbf{Prevention Strategies}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Early follow-up appointment (within 7 days)
|
||||
\item Medication reconciliation and adherence check
|
||||
\item Symptom monitoring escalation
|
||||
\item Care coordinator phone call within 48 hours of discharge
|
||||
\item Access to nurse advice line 24/7
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Disease Progression Planning}
|
||||
|
||||
\textbf{If CKD progresses to Stage 4-5}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Nephrology referral for CKD education and dialysis planning
|
||||
\item Vascular access planning if eGFR $<$20
|
||||
\item Medication adjustments for reduced renal clearance
|
||||
\item Anemia management optimization (ESA if needed)
|
||||
\item Advance care planning discussions
|
||||
\end{itemize}
|
||||
|
||||
\textbf{If HF worsens to NYHA Class III-IV}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Consider ICD/CRT device evaluation
|
||||
\item Advanced therapies discussion (LVAD, transplant evaluation if appropriate)
|
||||
\item Palliative care consultation for symptom management
|
||||
\item Home health nursing for weight/symptom monitoring
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Advance Care Planning}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Goals of care discussion: [Patient preferences documented]
|
||||
\item Healthcare proxy: [Name, relationship] designated
|
||||
\item Advance directive: ☐ Completed / ☐ To complete
|
||||
\item CPR preferences: [Discussed, documented in chart]
|
||||
\item Dialysis preferences: Patient expresses desire to avoid if possible
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 9: FOLLOW-UP SCHEDULE =====
|
||||
\section*{9. Follow-Up and Reassessment Schedule}
|
||||
|
||||
\subsection*{Appointment Calendar}
|
||||
|
||||
\begin{longtable}{|l|l|p{7cm}|}
|
||||
\hline
|
||||
\textbf{Timeframe} & \textbf{Provider} & \textbf{Purpose} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Timeframe} & \textbf{Provider} & \textbf{Purpose} \\ \hline
|
||||
\endhead
|
||||
Week 2 & Care Coordinator (phone) & Check medication tolerability, answer questions, reinforce education \\ \hline
|
||||
Month 1 & PCP & Add empagliflozin, assess insulin titration, review home monitoring logs \\ \hline
|
||||
Month 2 & Dietitian & Nutrition counseling, meal planning, sodium/carb education \\ \hline
|
||||
Month 3 & PCP & HbA1c check, labs (CMP, lipids), medication review, preventive care update \\ \hline
|
||||
Month 3-4 & Cardiology & HF assessment, beta-blocker titration, consider ARNI \\ \hline
|
||||
Month 3-4 & Endocrinology & Diabetes management review, complications screening \\ \hline
|
||||
Month 6 & PCP & Comprehensive reassessment, all labs, update care plan, goal review \\ \hline
|
||||
Ongoing & Quarterly PCP & Chronic disease management visits \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Plan Reassessment}
|
||||
|
||||
This care plan will be formally reassessed and updated:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Every 6 months (routine)
|
||||
\item After hospitalization or ED visit
|
||||
\item With significant change in clinical status
|
||||
\item When new diagnoses are added
|
||||
\item When treatment goals are achieved or modified
|
||||
\item At patient or provider request
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 10: SIGNATURES =====
|
||||
\vspace{2em}
|
||||
|
||||
\section*{10. Provider Signature and Attestation}
|
||||
|
||||
This comprehensive chronic disease management plan has been reviewed with the patient. The patient demonstrates understanding of all chronic conditions, treatment goals, medications, lifestyle recommendations, self-monitoring requirements, warning signs, and when to seek care. Patient's values and preferences have been incorporated through shared decision-making.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Provider Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Provider Name/Credentials: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\[2em]
|
||||
\end{tabular}
|
||||
|
||||
\subsection*{Care Team Acknowledgment (Optional)}
|
||||
|
||||
Care team members have reviewed this integrated care plan and will coordinate care accordingly.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\textit{[Additional signature lines for cardiologist, endocrinologist, care coordinator as appropriate]}
|
||||
|
||||
\vspace{2em}
|
||||
\begin{center}
|
||||
\rule{\textwidth}{1pt}\\
|
||||
\textbf{End of Chronic Disease Management Plan}\\
|
||||
This document contains confidential patient information protected by HIPAA.
|
||||
\end{center}
|
||||
|
||||
\end{document}
|
||||
|
||||
% ========== NOTES FOR USERS ==========
|
||||
%
|
||||
% KEY FEATURES:
|
||||
% - Integrates multiple chronic conditions into unified plan
|
||||
% - Addresses medication interactions and contraindications across conditions
|
||||
% - Coordinates care across multiple specialistsUtilizes shared goals when conditions overlap (e.g., SGLT2i for DM + HF + CKD)
|
||||
% - Emphasizes patient self-management and activation
|
||||
% - Tracks quality measures and outcomes
|
||||
%
|
||||
% CUSTOMIZATION:
|
||||
% - Adjust problem list based on patient's specific conditions
|
||||
% - Modify goals for disease severity and patient capabilities
|
||||
% - Adapt medication regimen to formulary and patient tolerance
|
||||
% - Coordinate specialist involvement based on availability and need
|
||||
%
|
||||
% COMPILATION:
|
||||
% pdflatex chronic_disease_management_plan.tex
|
||||
|
||||
547
skills/treatment-plans/assets/general_medical_treatment_plan.tex
Normal file
547
skills/treatment-plans/assets/general_medical_treatment_plan.tex
Normal file
@@ -0,0 +1,547 @@
|
||||
% General Medical Treatment Plan Template
|
||||
% For primary care and chronic disease management
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[11pt,letterpaper]{article}
|
||||
|
||||
% Packages
|
||||
\usepackage[top=1in,bottom=1in,left=1in,right=1in]{geometry}
|
||||
\usepackage{amsmath,amssymb}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{graphicx}
|
||||
\usepackage{array}
|
||||
\usepackage{longtable}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{lastpage}
|
||||
\usepackage{tabularx}
|
||||
\usepackage[most]{tcolorbox}
|
||||
|
||||
% Header and footer
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\lhead{General Medical Treatment Plan}
|
||||
\rhead{Page \thepage\ of \pageref{LastPage}}
|
||||
\lfoot{Date Created: \today}
|
||||
\rfoot{Confidential Patient Information}
|
||||
|
||||
% Title formatting
|
||||
\usepackage{titlesec}
|
||||
\titleformat{\section}{\large\bfseries}{\thesection}{1em}{}
|
||||
\titleformat{\subsection}{\normalsize\bfseries}{\thesubsection}{1em}{}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% Title
|
||||
\begin{center}
|
||||
{\Large\bfseries MEDICAL TREATMENT PLAN}\\[0.5em]
|
||||
{\large General Medicine \& Chronic Disease Management}\\[0.5em]
|
||||
\rule{\textwidth}{1pt}
|
||||
\end{center}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== TREATMENT PLAN HIGHLIGHTS (Foundation Medicine Model) =====
|
||||
\begin{tcolorbox}[colback=blue!5!white,colframe=blue!75!black,title=\textbf{TREATMENT PLAN HIGHLIGHTS},fonttitle=\bfseries\large]
|
||||
|
||||
\textbf{Key Diagnosis:} [Primary diagnosis with ICD-10 code, severity/stage]
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Primary Treatment Goals:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item [Goal 1 - e.g., Reduce HbA1c from 8.5\% to $<$7\% within 3 months]
|
||||
\item [Goal 2 - e.g., Achieve blood pressure $<$130/80 mmHg within 8 weeks]
|
||||
\item [Goal 3 - e.g., Weight loss of 7-10\% body weight over 6 months]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Main Interventions:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Pharmacological:} [Key medications - e.g., Metformin 1000mg BID, Lisinopril 10mg daily]
|
||||
\item \textit{Non-pharmacological:} [Lifestyle modifications - e.g., Mediterranean diet, 150 min/week exercise]
|
||||
\item \textit{Monitoring:} [Key parameters - e.g., HbA1c every 3 months, home BP daily]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Timeline:} [Duration - e.g., Intensive initiation (4 weeks), Adjustment phase (8 weeks), Maintenance (ongoing)]
|
||||
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== SECTION 1: PATIENT INFORMATION =====
|
||||
\section*{1. Patient Information}
|
||||
|
||||
\textbf{HIPAA Notice}: All identifiable information must be removed or de-identified per Safe Harbor method before sharing this document. Remove: name, dates (except year), addresses, phone/fax, email, SSN, medical record numbers, account numbers, photos, and other unique identifiers.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Patient ID} & [De-identified code, e.g., PT-001] \\ \hline
|
||||
\textbf{Age Range} & [e.g., 55-60 years] \\ \hline
|
||||
\textbf{Sex} & [Male/Female/Other] \\ \hline
|
||||
\textbf{Race/Ethnicity} & [If relevant to treatment] \\ \hline
|
||||
\textbf{Date of Plan} & [Month/Year only] \\ \hline
|
||||
\textbf{Provider} & [Name, MD/DO/NP/PA, Credentials] \\ \hline
|
||||
\textbf{Facility} & [Healthcare facility name] \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\subsection*{Active Medical Conditions}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Primary Diagnosis}: [Condition with ICD-10 code]
|
||||
\item \textbf{Secondary Diagnoses}:
|
||||
\begin{itemize}
|
||||
\item [Comorbidity 1 with ICD-10 code]
|
||||
\item [Comorbidity 2 with ICD-10 code]
|
||||
\item [Additional conditions as needed]
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Current Medications}
|
||||
\begin{longtable}{|p{3.5cm}|p{2cm}|p{2cm}|p{5cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Indication} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Indication} \\ \hline
|
||||
\endhead
|
||||
Medication 1 & [e.g., 10mg] & [e.g., daily] & [Indication] \\ \hline
|
||||
Medication 2 & [e.g., 50mg] & [e.g., BID] & [Indication] \\ \hline
|
||||
[Add rows as needed] & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Allergies}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Drug Allergies}: [List medications and reactions, or NKDA]
|
||||
\item \textbf{Food/Environmental}: [If relevant to treatment]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Baseline Assessment}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Functional Status}: [Independent/requires assistance/dependent for ADLs]
|
||||
\item \textbf{Cognitive Status}: [Alert and oriented/impairment if present]
|
||||
\item \textbf{Social Support}: [Lives alone/with family, support system]
|
||||
\item \textbf{Key Baseline Values}: [e.g., HbA1c 8.5\%, BP 145/90, BMI 32, eGFR 55]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 2: DIAGNOSIS AND ASSESSMENT =====
|
||||
\section*{2. Diagnosis and Assessment Summary}
|
||||
|
||||
\subsection*{Primary Diagnosis}
|
||||
\textbf{Diagnosis}: [Full diagnosis name]\\
|
||||
\textbf{ICD-10 Code}: [e.g., E11.9 for Type 2 Diabetes Mellitus without complications]\\
|
||||
\textbf{Severity}: [Mild/Moderate/Severe or stage classification]\\
|
||||
\textbf{Duration}: [Time since diagnosis]
|
||||
|
||||
\subsection*{Clinical Presentation}
|
||||
[Describe current symptoms, functional limitations, and impact on quality of life. Include relevant exam findings and diagnostic test results.]
|
||||
|
||||
\subsection*{Risk Stratification}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Cardiovascular Risk}: [e.g., ASCVD 10-year risk 15\%]
|
||||
\item \textbf{Complications Risk}: [e.g., high risk for diabetic nephropathy]
|
||||
\item \textbf{Other Risk Factors}: [e.g., fall risk, frailty, polypharmacy]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Prognostic Considerations}
|
||||
[Discuss expected disease course, factors affecting prognosis, and rationale for treatment intensity.]
|
||||
|
||||
% ===== SECTION 3: TREATMENT GOALS =====
|
||||
\section*{3. Treatment Goals (SMART Format)}
|
||||
|
||||
\textbf{SMART Criteria}: All goals should be \textbf{S}pecific, \textbf{M}easurable, \textbf{A}chievable, \textbf{R}elevant, and \textbf{T}ime-bound.
|
||||
|
||||
\subsection*{Short-Term Goals (1-3 months)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Goal 1}: [e.g., Reduce HbA1c from 8.5\% to $<$7.5\%]
|
||||
\begin{itemize}
|
||||
\item \textit{Specific}: Reduce HbA1c by at least 1 percentage point
|
||||
\item \textit{Measurable}: HbA1c lab value
|
||||
\item \textit{Achievable}: With medication initiation and lifestyle changes
|
||||
\item \textit{Relevant}: Reduce microvascular complication risk
|
||||
\item \textit{Time-bound}: Achieve within 3 months (next follow-up)
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Goal 2}: [e.g., Decrease systolic blood pressure to $<$130 mmHg]
|
||||
\begin{itemize}
|
||||
\item \textit{Specific}: Achieve BP $<$130/80 mmHg
|
||||
\item \textit{Measurable}: Office and home BP measurements
|
||||
\item \textit{Achievable}: With medication optimization
|
||||
\item \textit{Relevant}: Reduce cardiovascular event risk
|
||||
\item \textit{Time-bound}: Within 8 weeks
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Goal 3}: [Additional short-term goal]
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{Long-Term Goals (6-12 months)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Goal 1}: [e.g., Maintain HbA1c $<$7\% and prevent diabetic complications]
|
||||
\begin{itemize}
|
||||
\item \textit{Success criteria}: HbA1c $<$7\%, no new retinopathy/nephropathy/neuropathy
|
||||
\item \textit{Timeline}: Ongoing, assessed every 3-6 months
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Goal 2}: [e.g., Weight loss of 15 pounds (7\% body weight)]
|
||||
\begin{itemize}
|
||||
\item \textit{Success criteria}: BMI reduction from 32 to $<$30
|
||||
\item \textit{Timeline}: 6-12 months at 1-2 lbs/week
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Goal 3}: [e.g., Achieve LDL cholesterol $<$70 mg/dL]
|
||||
|
||||
\item \textbf{Goal 4}: [Additional long-term goal as needed]
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{Patient-Centered Goals}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Patient Priority 1}: [e.g., "Feel more energetic throughout the day"]
|
||||
\item \textbf{Patient Priority 2}: [e.g., "Avoid insulin injections if possible"]
|
||||
\item \textbf{Patient Priority 3}: [e.g., "Continue working full-time"]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 4: INTERVENTIONS =====
|
||||
\section*{4. Interventions}
|
||||
|
||||
\subsection*{4.1 Pharmacological Interventions}
|
||||
|
||||
\begin{longtable}{|p{3cm}|p{2cm}|p{2cm}|p{6.5cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Instructions \& Rationale} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Instructions \& Rationale} \\ \hline
|
||||
\endhead
|
||||
|
||||
[e.g., Metformin] & 500mg & BID & \textbf{Start:} Take with meals to reduce GI upset. \textbf{Titration:} Increase to 1000mg BID after 2 weeks if tolerated. \textbf{Target:} 2000mg daily. \textbf{Rationale:} First-line for T2DM, reduces hepatic glucose production. \\ \hline
|
||||
|
||||
[e.g., Lisinopril] & 10mg & Daily & \textbf{Instructions:} Take in morning. Monitor BP at home. \textbf{Titration:} May increase to 20mg if BP not at goal in 4 weeks. \textbf{Rationale:} ACE inhibitor for HTN and renal protection in diabetes. \\ \hline
|
||||
|
||||
[Additional medications] & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Medication Safety Considerations}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Drug Interactions}: [List relevant interactions to monitor]
|
||||
\item \textbf{Adverse Effects to Monitor}: [e.g., metformin - GI upset, lactic acidosis; lisinopril - cough, hyperkalemia, angioedema]
|
||||
\item \textbf{Contraindications}: [e.g., metformin if eGFR $<$30]
|
||||
\item \textbf{Pregnancy Category}: [If relevant to patient]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.2 Non-Pharmacological Interventions}
|
||||
|
||||
\textbf{Lifestyle Modifications}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Diet}:
|
||||
\begin{itemize}
|
||||
\item Mediterranean or DASH diet pattern
|
||||
\item Carbohydrate counting: 45-60g per meal
|
||||
\item Reduce saturated fat $<$7\% of calories
|
||||
\item Sodium restriction $<$2300mg daily
|
||||
\item Referral to registered dietitian
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Exercise}:
|
||||
\begin{itemize}
|
||||
\item Aerobic exercise: 150 minutes/week moderate intensity (e.g., brisk walking 30 min 5x/week)
|
||||
\item Resistance training: 2-3 sessions/week
|
||||
\item Reduce sedentary time, stand/move every 30 minutes
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Smoking Cessation}: [If applicable]
|
||||
\begin{itemize}
|
||||
\item Nicotine replacement therapy (patch, gum, lozenge)
|
||||
\item Consider varenicline or bupropion
|
||||
\item Behavioral counseling: 1-800-QUIT-NOW
|
||||
\item Target quit date: [specific date within 1 month]
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Weight Management}:
|
||||
\begin{itemize}
|
||||
\item Target: 7-10\% body weight loss over 6 months
|
||||
\item Caloric deficit: 500-750 kcal/day
|
||||
\item Weekly self-weighing and food diary
|
||||
\item Consider weight loss program or app
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Sleep Hygiene}:
|
||||
\begin{itemize}
|
||||
\item Target 7-9 hours nightly
|
||||
\item Consistent sleep schedule
|
||||
\item Screen for sleep apnea if indicated
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Stress Management}:
|
||||
\begin{itemize}
|
||||
\item Mindfulness or meditation practice
|
||||
\item Stress reduction techniques
|
||||
\item Adequate social support
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Self-Management and Monitoring}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Blood Glucose Monitoring}: [Frequency, e.g., fasting and 2hr post-prandial 3x/week]
|
||||
\item \textbf{Home Blood Pressure}: [Frequency, e.g., daily in AM, record in log]
|
||||
\item \textbf{Weight Tracking}: [e.g., weekly on same day/time]
|
||||
\item \textbf{Symptom Diary}: [Track relevant symptoms]
|
||||
\item \textbf{Medication Adherence}: [Pill box, reminder app]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.3 Procedural and Referral Interventions}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Specialist Referrals}:
|
||||
\begin{itemize}
|
||||
\item [e.g., Endocrinology consultation for diabetes management]
|
||||
\item [e.g., Ophthalmology for annual dilated eye exam]
|
||||
\item [e.g., Podiatry for diabetic foot exam]
|
||||
\item [e.g., Nephrology if eGFR $<$30 or proteinuria]
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Diagnostic Testing Schedule}:
|
||||
\begin{itemize}
|
||||
\item [e.g., HbA1c every 3 months until at goal, then every 6 months]
|
||||
\item [e.g., Lipid panel annually]
|
||||
\item [e.g., Urine albumin-to-creatinine ratio annually]
|
||||
\item [e.g., Comprehensive metabolic panel every 6 months]
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Preventive Care}:
|
||||
\begin{itemize}
|
||||
\item Influenza vaccine annually
|
||||
\item Pneumococcal vaccines (PCV20 or PCV15+PPSV23)
|
||||
\item COVID-19 vaccination per current guidelines
|
||||
\item Age-appropriate cancer screenings
|
||||
\item [Other preventive measures as indicated]
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 5: TIMELINE AND SCHEDULE =====
|
||||
\section*{5. Timeline and Schedule}
|
||||
|
||||
\subsection*{Treatment Phases}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|X|}
|
||||
\hline
|
||||
\textbf{Phase} & \textbf{Timeframe} & \textbf{Focus} \\ \hline
|
||||
Intensive Initiation & Weeks 1-4 & Medication titration, lifestyle education, baseline monitoring \\ \hline
|
||||
Adjustment & Weeks 5-12 & Optimize medications, reinforce lifestyle changes, assess goal progress \\ \hline
|
||||
Maintenance & Months 4-12 & Sustain improvements, prevent complications, long-term adherence \\ \hline
|
||||
Ongoing & $>$12 months & Chronic disease management, annual assessments, update goals \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Appointment Schedule}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|X|}
|
||||
\hline
|
||||
\textbf{Timepoint} & \textbf{Visit Type} & \textbf{Key Activities} \\ \hline
|
||||
Week 2 & Phone/telehealth & Check medication tolerance, answer questions \\ \hline
|
||||
Week 4 & Office visit & Medication adjustment, BP check, labs, review monitoring \\ \hline
|
||||
Week 8 & Office visit & Assess progress toward goals, reinforce lifestyle \\ \hline
|
||||
Month 3 & Office visit & HbA1c, comprehensive assessment, goal evaluation \\ \hline
|
||||
Month 6 & Office visit & Reassess all goals, update plan, labs \\ \hline
|
||||
Month 12 & Annual exam & Comprehensive evaluation, preventive care, specialty referrals \\ \hline
|
||||
Ongoing & Every 3-6 months & Per chronic disease management protocol \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Milestone Assessments}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Month 1}: Medication tolerance, lifestyle initiation, home monitoring established
|
||||
\item \textbf{Month 3}: HbA1c $<$7.5\%, BP $<$130/80, 3-5 lb weight loss
|
||||
\item \textbf{Month 6}: HbA1c $<$7\%, sustained BP control, 8-10 lb weight loss
|
||||
\item \textbf{Month 12}: All long-term goals achieved or revised, complication screening complete
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 6: MONITORING PARAMETERS =====
|
||||
\section*{6. Monitoring Parameters}
|
||||
|
||||
\subsection*{Clinical Outcomes to Track}
|
||||
|
||||
\begin{longtable}{|p{4cm}|p{3cm}|p{3cm}|p{4cm}|}
|
||||
\hline
|
||||
\textbf{Parameter} & \textbf{Baseline} & \textbf{Target} & \textbf{Frequency} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Parameter} & \textbf{Baseline} & \textbf{Target} & \textbf{Frequency} \\ \hline
|
||||
\endhead
|
||||
|
||||
HbA1c & [e.g., 8.5\%] & $<$7\% & Every 3 months until stable, then every 6 months \\ \hline
|
||||
Fasting Glucose & [e.g., 165 mg/dL] & 80-130 mg/dL & Home monitoring per schedule \\ \hline
|
||||
Blood Pressure & [e.g., 145/90] & $<$130/80 mmHg & Daily home, every office visit \\ \hline
|
||||
Weight/BMI & [e.g., 210 lb, BMI 32] & 195 lb, BMI $<$30 & Weekly at home, every visit \\ \hline
|
||||
LDL Cholesterol & [e.g., 135 mg/dL] & $<$70 mg/dL & Every 6-12 months \\ \hline
|
||||
eGFR & [e.g., 55 mL/min] & Stable, $>$45 & Every 6 months \\ \hline
|
||||
Urine ACR & [e.g., normal] & $<$30 mg/g & Annually \\ \hline
|
||||
[Add additional parameters] & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Assessment Tools and Scales}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Diabetes Distress Scale}: [Assess emotional burden of diabetes management]
|
||||
\item \textbf{SF-12 or PROMIS}: [Quality of life assessment]
|
||||
\item \textbf{Medication Adherence}: [Morisky scale or refill tracking]
|
||||
\item \textbf{[Other relevant scales]}: [e.g., PHQ-2 for depression screening]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Safety Monitoring}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Hypoglycemia}: Frequency of blood glucose $<$70 mg/dL, symptoms
|
||||
\item \textbf{Medication Adverse Effects}: GI upset, cough, dizziness, other symptoms
|
||||
\item \textbf{Hyperkalemia}: Potassium level if on ACE inhibitor/ARB
|
||||
\item \textbf{Renal Function}: Monitor eGFR for metformin safety, ACE/ARB effects
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Thresholds for Intervention}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Urgent}: Blood glucose $>$300 or $<$50, BP $>$180/110, chest pain, severe symptoms
|
||||
\item \textbf{Escalate Treatment}: No improvement in HbA1c after 3 months, BP above goal after 8 weeks
|
||||
\item \textbf{Modify Plan}: Intolerable side effects, patient preference change, new comorbidities
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 7: EXPECTED OUTCOMES =====
|
||||
\section*{7. Expected Outcomes and Prognosis}
|
||||
|
||||
\textbf{Anticipated Treatment Response}: With adherence, expect HbA1c reduction of 1-1.5\%, BP reduction of 10-15 mmHg, and 5-10\% weight loss over 6 months. Improvements visible at 4-8 weeks (BP, glucose), with HbA1c changes by 3 months.
|
||||
|
||||
\vspace{0.5em}
|
||||
\textbf{Long-Term Benefits}: Reduced complication risk (cardiovascular events, retinopathy, nephropathy), improved quality of life, maintained independence and functional status.
|
||||
|
||||
% ===== SECTION 8: FOLLOW-UP PLAN =====
|
||||
\section*{8. Follow-Up Plan}
|
||||
|
||||
\subsection*{Scheduled Appointments}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Next Visit}: [Date/timeframe - e.g., 4 weeks from today]
|
||||
\item \textbf{Visit Purpose}: [Medication adjustment, lab review, goal assessment]
|
||||
\item \textbf{Ongoing Schedule}: See Appointment Schedule in Section 5
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Communication Plan}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Between-Visit Contact}: Phone call at 2 weeks to assess medication tolerance
|
||||
\item \textbf{Lab Results}: Will call with results within 3-5 business days
|
||||
\item \textbf{Questions}: Call office at [phone], patient portal messaging
|
||||
\item \textbf{Prescription Refills}: Via patient portal or pharmacy automated refill
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Emergency Procedures}
|
||||
|
||||
\textbf{Call 911 immediately for}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Chest pain, shortness of breath, or stroke symptoms
|
||||
\item Severe hypoglycemia with confusion or loss of consciousness
|
||||
\item Severe allergic reaction (angioedema, anaphylaxis)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Call office same day for}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Blood glucose consistently $>$300 or $<$60 mg/dL
|
||||
\item Blood pressure $>$180/110 mmHg
|
||||
\item Persistent severe medication side effects
|
||||
\item Fever, infection, or acute illness (may need medication adjustment)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Transition Planning}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{If Hospitalized}: Provide this treatment plan to hospital team, resume medications on discharge
|
||||
\item \textbf{Specialist Co-Management}: Share plan with all specialists, coordinate medication changes
|
||||
\item \textbf{Future Considerations}: [e.g., may need insulin if oral medications insufficient]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 9: PATIENT EDUCATION =====
|
||||
\section*{9. Patient Education and Self-Management}
|
||||
|
||||
\textbf{Key Education Topics}: Disease understanding, complication risks, treatment rationale, self-monitoring techniques (glucose, BP), medication administration, diet/nutrition basics, exercise safety, sick day management.
|
||||
|
||||
\vspace{0.5em}
|
||||
\textbf{Critical Warning Signs}:
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Emergency (call 911)}: Chest pain, severe hypoglycemia with confusion, stroke symptoms
|
||||
\item \textit{Call office same day}: Glucose $>$300 or $<$60 mg/dL, BP $>$180/110, severe medication side effects
|
||||
\item \textit{Urgent evaluation}: Diabetic foot wounds, severe hyperglycemia with symptoms
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.5em}
|
||||
\textbf{Support Resources}: DSMES referral, registered dietitian, educational materials, support groups, tracking technology, financial assistance programs as needed.
|
||||
|
||||
% ===== SECTION 10: RISK MITIGATION AND SAFETY =====
|
||||
\section*{10. Risk Mitigation and Safety}
|
||||
|
||||
\textbf{Key Medication Safety Concerns}:
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Metformin}: Monitor eGFR every 6 months; hold if eGFR $<$30, during acute illness, or 48 hours before contrast
|
||||
\item \textit{ACE inhibitor}: Check K+ and creatinine at 1-2 weeks, then every 6 months; hold during dehydration/AKI
|
||||
\item \textit{Hypoglycemia}: Low risk without insulin/sulfonylureas; educate on recognition and 15-15 rule
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.5em}
|
||||
\textbf{Complication Prevention}: Annual eye exam, foot exam, and urine ACR; aspirin if ASCVD risk $>$10\%; BP and glucose control reduces cardiovascular, retinopathy, nephropathy, and neuropathy risks.
|
||||
|
||||
\vspace{0.5em}
|
||||
\textbf{Emergency Actions}: Severe hypoglycemia ($<$50, confusion) - glucagon then 911; chest pain/stroke - call 911; hyperglycemia $>$300 with symptoms - hydrate and call office; severe medication side effects - stop medication, call same day.
|
||||
|
||||
% ===== SECTION 11: PROVIDER SIGNATURE =====
|
||||
\vspace{2em}
|
||||
|
||||
\section*{11. Provider Signature and Attestation}
|
||||
|
||||
I have reviewed this treatment plan with the patient. The patient demonstrates understanding of the diagnosis, treatment rationale, goals, interventions, self-management requirements, warning signs, and when to seek emergency care. The patient agrees to this treatment plan and has had the opportunity to ask questions. Shared decision-making was employed, and patient preferences were incorporated.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Provider Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Provider Name/Credentials: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\[2em]
|
||||
\end{tabular}
|
||||
|
||||
\subsection*{Patient Acknowledgment (Optional)}
|
||||
|
||||
I have reviewed this treatment plan with my healthcare provider. I understand my diagnosis, treatment goals, medications, lifestyle recommendations, self-monitoring requirements, and when to seek medical attention. I agree to follow this plan and contact my provider with questions or concerns.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Patient/Representative Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\
|
||||
\end{tabular}
|
||||
|
||||
\vspace{2em}
|
||||
\begin{center}
|
||||
\rule{\textwidth}{1pt}\\
|
||||
\textbf{End of Treatment Plan}\\
|
||||
This document contains confidential patient information protected by HIPAA.
|
||||
\end{center}
|
||||
|
||||
\end{document}
|
||||
|
||||
% ========== NOTES FOR USERS ==========
|
||||
%
|
||||
% CUSTOMIZATION INSTRUCTIONS:
|
||||
% 1. Replace all bracketed placeholders [like this] with patient-specific information
|
||||
% 2. Remove or add sections as appropriate for the clinical condition
|
||||
% 3. Ensure all SMART goals meet criteria (Specific, Measurable, Achievable, Relevant, Time-bound)
|
||||
% 4. Include evidence-based interventions per current clinical guidelines
|
||||
% 5. De-identify all protected health information before sharing
|
||||
%
|
||||
% COMPILATION:
|
||||
% pdflatex general_medical_treatment_plan.tex
|
||||
%
|
||||
% VALIDATION:
|
||||
% Run check_completeness.py and validate_treatment_plan.py before finalizing
|
||||
|
||||
222
skills/treatment-plans/assets/medical_treatment_plan.sty
Normal file
222
skills/treatment-plans/assets/medical_treatment_plan.sty
Normal file
@@ -0,0 +1,222 @@
|
||||
% medical_treatment_plan.sty
|
||||
% Professional Medical Treatment Plan Style
|
||||
% Provides modern, clean styling for clinical treatment plans
|
||||
|
||||
\NeedsTeXFormat{LaTeX2e}
|
||||
\ProvidesPackage{medical_treatment_plan}[2025/11/05 Medical Treatment Plan Style]
|
||||
|
||||
% Required packages
|
||||
\RequirePackage[margin=1in, top=1.2in, bottom=1.2in]{geometry}
|
||||
\RequirePackage{graphicx}
|
||||
\RequirePackage{xcolor}
|
||||
\RequirePackage[most]{tcolorbox}
|
||||
\RequirePackage{tikz}
|
||||
\RequirePackage{fontspec}
|
||||
\RequirePackage{fancyhdr}
|
||||
\RequirePackage{titlesec}
|
||||
\RequirePackage{enumitem}
|
||||
\RequirePackage{booktabs}
|
||||
\RequirePackage{longtable}
|
||||
\RequirePackage{array}
|
||||
\RequirePackage{colortbl}
|
||||
\RequirePackage{hyperref}
|
||||
\RequirePackage{natbib}
|
||||
|
||||
% Color scheme - Professional medical blues and grays
|
||||
\definecolor{primaryblue}{RGB}{0, 102, 153} % Deep medical blue
|
||||
\definecolor{secondaryblue}{RGB}{102, 178, 204} % Light blue
|
||||
\definecolor{accentblue}{RGB}{0, 153, 204} % Bright accent
|
||||
\definecolor{darkgray}{RGB}{64, 64, 64} % Dark gray for text
|
||||
\definecolor{lightgray}{RGB}{245, 245, 245} % Light background
|
||||
\definecolor{medgray}{RGB}{200, 200, 200} % Medium gray
|
||||
\definecolor{warningred}{RGB}{204, 0, 0} % For warnings
|
||||
\definecolor{successgreen}{RGB}{0, 153, 76} % For success/goals
|
||||
|
||||
% Fonts (if using XeLaTeX/LuaLaTeX) - use default fonts if custom fonts not available
|
||||
% \IfFileExists{lato}{\setmainfont{Lato}}{}
|
||||
% \IfFileExists{roboto}{\setsansfont{Roboto}}{}
|
||||
|
||||
% Hyperlink setup
|
||||
\hypersetup{
|
||||
colorlinks=true,
|
||||
linkcolor=primaryblue,
|
||||
citecolor=primaryblue,
|
||||
urlcolor=accentblue,
|
||||
pdfborder={0 0 0}
|
||||
}
|
||||
|
||||
% Header and footer styling
|
||||
\setlength{\headheight}{22pt}
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\fancyhead[L]{\color{primaryblue}\sffamily\small\textbf{Diabetes Treatment Plan}}
|
||||
\fancyhead[R]{\color{darkgray}\sffamily\small Patient Age: 23}
|
||||
\fancyfoot[C]{\color{darkgray}\small\thepage}
|
||||
\renewcommand{\headrulewidth}{2pt}
|
||||
\renewcommand{\headrule}{\hbox to\headwidth{\color{primaryblue}\leaders\hrule height \headrulewidth\hfill}}
|
||||
\renewcommand{\footrulewidth}{0.5pt}
|
||||
\renewcommand{\footrule}{\hbox to\headwidth{\color{medgray}\leaders\hrule height \footrulewidth\hfill}}
|
||||
|
||||
% Section styling
|
||||
\titleformat{\section}
|
||||
{\color{primaryblue}\Large\sffamily\bfseries}
|
||||
{\thesection}{1em}{}
|
||||
[\color{primaryblue}\titlerule]
|
||||
|
||||
\titleformat{\subsection}
|
||||
{\color{accentblue}\large\sffamily\bfseries}
|
||||
{\thesubsection}{1em}{}
|
||||
|
||||
\titleformat{\subsubsection}
|
||||
{\color{darkgray}\normalsize\sffamily\bfseries}
|
||||
{\thesubsubsection}{1em}{}
|
||||
|
||||
% Title page styling
|
||||
\renewcommand{\maketitle}{
|
||||
\begin{tcolorbox}[
|
||||
enhanced,
|
||||
colback=primaryblue,
|
||||
colframe=primaryblue,
|
||||
arc=0mm,
|
||||
boxrule=0pt,
|
||||
left=20pt,
|
||||
right=20pt,
|
||||
top=30pt,
|
||||
bottom=30pt,
|
||||
width=\textwidth
|
||||
]
|
||||
\color{white}
|
||||
\begin{center}
|
||||
{\Huge\sffamily\bfseries Individualized Diabetes\\Treatment Plan}\\[10pt]
|
||||
{\Large\sffamily 23-Year-Old Male Patient with Type 2 Diabetes}\\[15pt]
|
||||
{\large\sffamily Comprehensive Evidence-Based Care Plan}\\[8pt]
|
||||
{\normalsize\sffamily\color{secondaryblue}\today}
|
||||
\end{center}
|
||||
\end{tcolorbox}
|
||||
\vspace{1cm}
|
||||
}
|
||||
|
||||
% Custom boxes for different content types
|
||||
% Info box
|
||||
\newtcolorbox{infobox}[1][]{
|
||||
enhanced,
|
||||
colback=lightgray,
|
||||
colframe=primaryblue,
|
||||
arc=3mm,
|
||||
boxrule=1.5pt,
|
||||
left=10pt,
|
||||
right=10pt,
|
||||
top=10pt,
|
||||
bottom=10pt,
|
||||
title=#1,
|
||||
fonttitle=\sffamily\bfseries,
|
||||
coltitle=white,
|
||||
colbacktitle=primaryblue
|
||||
}
|
||||
|
||||
% Warning box
|
||||
\newtcolorbox{warningbox}[1][Warning]{
|
||||
enhanced,
|
||||
colback=yellow!10,
|
||||
colframe=warningred,
|
||||
arc=3mm,
|
||||
boxrule=1.5pt,
|
||||
left=10pt,
|
||||
right=10pt,
|
||||
top=10pt,
|
||||
bottom=10pt,
|
||||
title=#1,
|
||||
fonttitle=\sffamily\bfseries,
|
||||
coltitle=white,
|
||||
colbacktitle=warningred
|
||||
}
|
||||
|
||||
% Goal box
|
||||
\newtcolorbox{goalbox}[1][Treatment Goals]{
|
||||
enhanced,
|
||||
colback=green!5,
|
||||
colframe=successgreen,
|
||||
arc=3mm,
|
||||
boxrule=1.5pt,
|
||||
left=10pt,
|
||||
right=10pt,
|
||||
top=10pt,
|
||||
bottom=10pt,
|
||||
title=#1,
|
||||
fonttitle=\sffamily\bfseries,
|
||||
coltitle=white,
|
||||
colbacktitle=successgreen
|
||||
}
|
||||
|
||||
% Key points box
|
||||
\newtcolorbox{keybox}[1][Key Points]{
|
||||
enhanced,
|
||||
colback=secondaryblue!10,
|
||||
colframe=accentblue,
|
||||
arc=3mm,
|
||||
boxrule=1.5pt,
|
||||
left=10pt,
|
||||
right=10pt,
|
||||
top=10pt,
|
||||
bottom=10pt,
|
||||
title=#1,
|
||||
fonttitle=\sffamily\bfseries,
|
||||
coltitle=white,
|
||||
colbacktitle=accentblue
|
||||
}
|
||||
|
||||
% Table styling
|
||||
\newcommand{\tableheadercolor}{\rowcolor{primaryblue}}
|
||||
\newcommand{\tablerowcolor}{\rowcolor{lightgray}}
|
||||
|
||||
% Custom table environment
|
||||
\newenvironment{medtable}[1]{
|
||||
\begin{table}[h]
|
||||
\centering
|
||||
\small\sffamily
|
||||
\renewcommand{\arraystretch}{1.3}
|
||||
}{
|
||||
\end{table}
|
||||
}
|
||||
|
||||
% Patient info section style
|
||||
\newenvironment{patientinfo}{
|
||||
\begin{tcolorbox}[
|
||||
enhanced,
|
||||
colback=white,
|
||||
colframe=secondaryblue,
|
||||
arc=2mm,
|
||||
boxrule=1pt,
|
||||
left=15pt,
|
||||
right=15pt,
|
||||
top=12pt,
|
||||
bottom=12pt
|
||||
]
|
||||
\sffamily
|
||||
}{
|
||||
\end{tcolorbox}
|
||||
}
|
||||
|
||||
% Custom list styling
|
||||
\setlist[itemize,1]{label=\textcolor{primaryblue}{\textbullet}, leftmargin=*, itemsep=3pt}
|
||||
\setlist[enumerate,1]{label=\textcolor{primaryblue}{\arabic*.}, leftmargin=*, itemsep=3pt}
|
||||
|
||||
% Emergency contact box
|
||||
\newtcolorbox{emergencybox}{
|
||||
enhanced,
|
||||
colback=warningred!5,
|
||||
colframe=warningred,
|
||||
arc=3mm,
|
||||
boxrule=2pt,
|
||||
left=15pt,
|
||||
right=15pt,
|
||||
top=15pt,
|
||||
bottom=15pt,
|
||||
title=EMERGENCY CONTACTS,
|
||||
fonttitle=\sffamily\bfseries\Large,
|
||||
coltitle=white,
|
||||
colbacktitle=warningred
|
||||
}
|
||||
|
||||
\endinput
|
||||
|
||||
774
skills/treatment-plans/assets/mental_health_treatment_plan.tex
Normal file
774
skills/treatment-plans/assets/mental_health_treatment_plan.tex
Normal file
@@ -0,0 +1,774 @@
|
||||
% Mental Health Treatment Plan Template
|
||||
% For psychiatric and behavioral health treatment
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[11pt,letterpaper]{article}
|
||||
|
||||
% Packages
|
||||
\usepackage[top=1in,bottom=1in,left=1in,right=1in]{geometry}
|
||||
\usepackage{amsmath,amssymb}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{graphicx}
|
||||
\usepackage{array}
|
||||
\usepackage{longtable}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{lastpage}
|
||||
\usepackage{tabularx}
|
||||
\usepackage[most]{tcolorbox}
|
||||
|
||||
% Header and footer
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\lhead{Mental Health Treatment Plan}
|
||||
\rhead{Page \thepage\ of \pageref{LastPage}}
|
||||
\lfoot{Date Created: \today}
|
||||
\rfoot{Confidential Patient Information}
|
||||
|
||||
% Title formatting
|
||||
\usepackage{titlesec}
|
||||
\titleformat{\section}{\large\bfseries}{\thesection}{1em}{}
|
||||
\titleformat{\subsection}{\normalsize\bfseries}{\thesubsection}{1em}{}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% Title
|
||||
\begin{center}
|
||||
{\Large\bfseries MENTAL HEALTH TREATMENT PLAN}\\[0.5em]
|
||||
{\large Psychiatric \& Behavioral Health Services}\\[0.5em]
|
||||
\rule{\textwidth}{1pt}
|
||||
\end{center}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== TREATMENT PLAN HIGHLIGHTS (Foundation Medicine Model) =====
|
||||
\begin{tcolorbox}[colback=purple!5!white,colframe=purple!75!black,title=\textbf{TREATMENT PLAN HIGHLIGHTS},fonttitle=\bfseries\large]
|
||||
|
||||
\textbf{Key Diagnosis:} [Primary psychiatric diagnosis - e.g., Major Depressive Disorder, moderate (DSM-5 296.32)]
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Primary Treatment Goals:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item [Goal 1 - e.g., Reduce PHQ-9 score from 18 to $<$10 within 12 weeks]
|
||||
\item [Goal 2 - e.g., Return to work full-time within 3 months]
|
||||
\item [Goal 3 - e.g., Develop 3 effective coping strategies for stress management]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Main Interventions:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Psychotherapy:} [Modality - e.g., Cognitive Behavioral Therapy (CBT) weekly for 16 sessions]
|
||||
\item \textit{Medication:} [Key medications - e.g., Sertraline 50mg daily, titrate to 100mg]
|
||||
\item \textit{Safety:} [Crisis plan in place, emergency contacts established]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Timeline:} [Duration - e.g., Acute treatment (12 weeks), Continuation (4-6 months), Maintenance (ongoing)]
|
||||
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== SECTION 1: PATIENT INFORMATION =====
|
||||
\section*{1. Patient Information}
|
||||
|
||||
\textbf{HIPAA Notice}: De-identify all protected health information per Safe Harbor method before sharing.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Patient ID} & [De-identified code, e.g., MH-001] \\ \hline
|
||||
\textbf{Age Range} & [e.g., 30-35 years] \\ \hline
|
||||
\textbf{Sex} & [Male/Female/Other] \\ \hline
|
||||
\textbf{Gender Identity} & [If relevant and disclosed] \\ \hline
|
||||
\textbf{Pronouns} & [Patient's preferred pronouns] \\ \hline
|
||||
\textbf{Date of Plan} & [Month/Year only] \\ \hline
|
||||
\textbf{Treating Provider} & [Psychiatrist/Psychologist/LCSW/NP Name, Credentials] \\ \hline
|
||||
\textbf{Treatment Setting} & [Outpatient/IOP/PHP/Inpatient] \\ \hline
|
||||
\textbf{Facility} & [Mental health center/clinic name] \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\subsection*{Presenting Problem}
|
||||
|
||||
\textbf{Chief Complaint}: [Patient's own words, e.g., "I've been feeling really down and can't get motivated to do anything"]
|
||||
|
||||
\textbf{History of Present Illness}:
|
||||
[Detailed description of current symptoms, onset, duration, severity, precipitating factors, impact on functioning. Example: Patient reports depressed mood, anhedonia, fatigue, and difficulty concentrating for past 3 months, following job loss. Symptoms have progressively worsened, now affecting ability to complete daily tasks and maintain social relationships.]
|
||||
|
||||
\subsection*{Psychiatric History}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Previous Psychiatric Diagnoses}: [e.g., Major Depressive Disorder, diagnosed 5 years ago]
|
||||
\item \textbf{Previous Treatment}:
|
||||
\begin{itemize}
|
||||
\item Psychotherapy: [e.g., CBT for 6 months in 2020, helpful]
|
||||
\item Medications: [e.g., Sertraline 100mg 2020-2021, discontinued due to side effects]
|
||||
\item Hospitalizations: [e.g., One psychiatric hospitalization in 2019 for suicidal ideation]
|
||||
\end{itemize}
|
||||
\item \textbf{Family Psychiatric History}: [e.g., Mother with depression, paternal uncle with bipolar disorder]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Substance Use History}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Alcohol}: [e.g., Social use, 2-3 drinks per week, denies binge drinking]
|
||||
\item \textbf{Tobacco}: [e.g., Non-smoker]
|
||||
\item \textbf{Cannabis}: [e.g., Previously daily use, quit 6 months ago]
|
||||
\item \textbf{Other Substances}: [e.g., Denies other illicit drug use]
|
||||
\item \textbf{Substance Use Disorder}: [e.g., Cannabis use disorder, in remission]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Medical History}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Chronic Medical Conditions}: [e.g., Hypothyroidism, well-controlled on levothyroxine]
|
||||
\item \textbf{Current Medications}: [e.g., Levothyroxine 100mcg daily]
|
||||
\item \textbf{Allergies}: [NKDA or list medication allergies and reactions]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Social History and Support}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Living Situation}: [e.g., Lives alone in apartment, safe housing]
|
||||
\item \textbf{Employment}: [e.g., Recently unemployed (3 months), previously worked as accountant]
|
||||
\item \textbf{Education}: [e.g., Bachelor's degree in accounting]
|
||||
\item \textbf{Marital/Relationship Status}: [e.g., Single, not in relationship]
|
||||
\item \textbf{Social Support}: [e.g., Close relationship with sister, few friends, isolated recently]
|
||||
\item \textbf{Financial Stressors}: [e.g., Unemployment causing financial strain]
|
||||
\item \textbf{Legal Issues}: [e.g., None]
|
||||
\item \textbf{Trauma History}: [e.g., Reports childhood emotional abuse, no recent trauma]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 2: PSYCHIATRIC ASSESSMENT =====
|
||||
\section*{2. Psychiatric Assessment and Diagnosis}
|
||||
|
||||
\subsection*{Mental Status Examination}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Appearance}: [e.g., Casually dressed, fair grooming, appropriate for season]
|
||||
\item \textbf{Behavior}: [e.g., Cooperative, fair eye contact, psychomotor retardation noted]
|
||||
\item \textbf{Speech}: [e.g., Soft volume, slow rate, decreased spontaneity]
|
||||
\item \textbf{Mood}: [e.g., "Depressed and hopeless" - patient's own words]
|
||||
\item \textbf{Affect}: [e.g., Constricted, dysphoric, congruent with mood]
|
||||
\item \textbf{Thought Process}: [e.g., Linear, goal-directed, no tangentiality or loose associations]
|
||||
\item \textbf{Thought Content}:
|
||||
\begin{itemize}
|
||||
\item Suicidal ideation: [e.g., Passive SI present ("wish I wouldn't wake up"), denies active SI/plan/intent]
|
||||
\item Homicidal ideation: [e.g., Denied]
|
||||
\item Delusions: [e.g., None identified]
|
||||
\item Obsessions/compulsions: [e.g., None]
|
||||
\end{itemize}
|
||||
\item \textbf{Perceptions}: [e.g., No hallucinations (auditory, visual, tactile) reported or observed]
|
||||
\item \textbf{Cognition}:
|
||||
\begin{itemize}
|
||||
\item Orientation: [e.g., Oriented to person, place, time, situation]
|
||||
\item Memory: [e.g., Intact for recent and remote events]
|
||||
\item Concentration: [e.g., Impaired, difficulty with serial 7s]
|
||||
\item Insight: [e.g., Fair - recognizes need for treatment]
|
||||
\item Judgment: [e.g., Fair to good - makes reasonable decisions]
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Diagnostic Assessment}
|
||||
|
||||
\textbf{Primary Diagnosis}: [e.g., Major Depressive Disorder, Recurrent Episode, Moderate]\\
|
||||
\textbf{DSM-5 Code}: [e.g., F33.1]
|
||||
|
||||
\textbf{DSM-5 Criteria Met}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Depressed mood most of the day, nearly every day (patient report, observed affect)
|
||||
\item Markedly diminished interest or pleasure in activities (anhedonia)
|
||||
\item Significant weight loss (10 lbs in 2 months)
|
||||
\item Insomnia nearly every night (difficulty falling and staying asleep)
|
||||
\item Fatigue and loss of energy nearly every day
|
||||
\item Feelings of worthlessness and guilt
|
||||
\item Diminished ability to think and concentrate
|
||||
\item Duration: 3 months
|
||||
\item Significant distress and impairment in occupational and social functioning
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Secondary Diagnoses}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item [e.g., Cannabis Use Disorder, Mild, In Sustained Remission] (DSM-5: F12.11)
|
||||
\item [e.g., Unspecified Anxiety Disorder] (DSM-5: F41.9)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Symptom Severity Assessment}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|c|c|X|}
|
||||
\hline
|
||||
\textbf{Assessment Tool} & \textbf{Score} & \textbf{Interpretation} & \textbf{Notes} \\ \hline
|
||||
PHQ-9 (Depression) & 18/27 & Moderately severe depression & Target $<$10 for remission \\ \hline
|
||||
GAD-7 (Anxiety) & 12/21 & Moderate anxiety & Target $<$5 \\ \hline
|
||||
PCL-5 (PTSD) & N/A & Not administered & Consider if trauma symptoms emerge \\ \hline
|
||||
C-SSRS (Suicide Risk) & Level 3 & Passive SI, no intent/plan & Requires safety planning \\ \hline
|
||||
AUDIT (Alcohol) & 3/40 & Low risk & No current concern \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Functional Impairment}
|
||||
|
||||
\textbf{Impact on Daily Functioning}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Occupational}: Unable to work currently, difficulty with job search due to lack of motivation
|
||||
\item \textbf{Social}: Withdrawn from friends, decreased social activities, isolating at home
|
||||
\item \textbf{Self-Care}: Difficulty maintaining hygiene, skipping meals, irregular sleep
|
||||
\item \textbf{Relationships}: Strained relationships due to irritability and withdrawal
|
||||
\item \textbf{Physical Health}: Decreased exercise, poor nutrition
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Risk Assessment}
|
||||
|
||||
\textbf{Suicide Risk}: [e.g., Low to Moderate]
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textit{Risk Factors}: Depression, unemployment, social isolation, passive SI, previous suicide attempt (2019)
|
||||
\item \textit{Protective Factors}: Engaged in treatment, close relationship with sister, denies current intent/plan, future-oriented (wants to get better)
|
||||
\item \textit{Current Status}: Passive SI only, no active ideation, plan, or intent. Contracts for safety.
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Homicide/Violence Risk}: [e.g., Low] - No homicidal ideation, no history of violence
|
||||
|
||||
% ===== SECTION 3: TREATMENT GOALS =====
|
||||
\section*{3. Treatment Goals (SMART Format)}
|
||||
|
||||
\subsection*{3.1 Short-Term Goals (4-8 weeks)}
|
||||
|
||||
\textbf{Symptom Reduction Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Depression}: Reduce PHQ-9 score from 18 to $<$10 (minimal depression) within 8 weeks through medication and psychotherapy.
|
||||
\begin{itemize}
|
||||
\item \textit{Measurable}: PHQ-9 assessment every 2 weeks
|
||||
\item \textit{Achievable}: With SSRI and weekly CBT
|
||||
\item \textit{Time-bound}: 8 weeks
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Sleep}: Improve sleep to 6-7 hours nightly with no more than 1 awakening within 4 weeks through sleep hygiene and possible medication adjustment.
|
||||
|
||||
\item \textbf{Anxiety}: Reduce GAD-7 score from 12 to $<$8 within 6 weeks using CBT anxiety management techniques.
|
||||
|
||||
\item \textbf{Suicide Risk}: Eliminate passive suicidal ideation, maintain safety contract, implement crisis plan within 2 weeks.
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Functional Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Self-Care}: Establish daily self-care routine (shower, meals, sleep schedule) with 80\% compliance within 3 weeks.
|
||||
|
||||
\item \textbf{Social Engagement}: Re-engage in 1-2 social activities per week (phone calls with friends, sister visits) within 4 weeks.
|
||||
|
||||
\item \textbf{Coping Skills}: Learn and practice 3 new coping skills for managing depressive symptoms within 4 weeks.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.2 Long-Term Goals (3-6 months)}
|
||||
|
||||
\textbf{Recovery-Oriented Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Remission}: Achieve depression remission with PHQ-9 score $<$5 and sustained improved mood within 12-16 weeks.
|
||||
|
||||
\item \textbf{Return to Work}: Develop job search plan, practice interview skills, secure employment or engage in meaningful volunteer work within 3-4 months.
|
||||
|
||||
\item \textbf{Relationship Building}: Rebuild and strengthen social connections, increase social support network by adding 2-3 regular social contacts within 3 months.
|
||||
|
||||
\item \textbf{Quality of Life}: Re-engage in previously enjoyed activities (hobbies, exercise, leisure) at least 3x per week within 3 months.
|
||||
|
||||
\item \textbf{Resilience}: Develop sustainable wellness routine including regular sleep, exercise, healthy diet, and stress management practices within 4 months.
|
||||
|
||||
\item \textbf{Relapse Prevention}: Identify early warning signs of depression, develop relapse prevention plan, maintain treatment gains within 6 months.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.3 Patient-Identified Goals}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Priority 1}: "I want to feel like myself again and have energy to do things"
|
||||
\item \textbf{Priority 2}: "I want to find a new job and feel confident in interviews"
|
||||
\item \textbf{Priority 3}: "I want to stop feeling guilty all the time"
|
||||
\item \textbf{Priority 4}: "I want to enjoy spending time with my friends and family again"
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 4: TREATMENT INTERVENTIONS =====
|
||||
\section*{4. Treatment Interventions}
|
||||
|
||||
\subsection*{4.1 Psychopharmacology}
|
||||
|
||||
\textbf{Medication Plan}:
|
||||
|
||||
\begin{longtable}{|p{3cm}|p{2cm}|p{2cm}|p{6.5cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Rationale \& Instructions} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Rationale \& Instructions} \\ \hline
|
||||
\endhead
|
||||
|
||||
Escitalopram (Lexapro) & 10mg & Daily (morning) & \textbf{Rationale}: First-line SSRI for major depression. \textbf{Start}: 10mg daily. \textbf{Titration}: May increase to 20mg after 4 weeks if partial response. \textbf{Expected}: 2-4 weeks for initial response, 6-8 weeks for full effect. \textbf{Monitor}: Mood, anxiety, suicidal ideation, side effects. \\ \hline
|
||||
|
||||
Trazodone & 50mg & QHS PRN & \textbf{Rationale}: For insomnia, sedating antidepressant. \textbf{Start}: 50mg at bedtime as needed. \textbf{Titration}: May increase to 100mg if ineffective. \textbf{Instructions}: Take 30 min before bed. May cause morning grogginess - reduce dose if bothersome. \\ \hline
|
||||
|
||||
[Continue current medications] & & & \\ \hline
|
||||
Levothyroxine & 100mcg & Daily & \textbf{Continue}: Hypothyroidism management. Monitor TSH every 6-12 months. \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Medication Safety and Monitoring}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Common Side Effects}: Nausea (take with food), headache, insomnia or drowsiness, sexual dysfunction (discuss if bothersome)
|
||||
\item \textbf{Serious Side Effects} (rare): Serotonin syndrome (agitation, confusion, rapid heart rate, high fever - seek emergency care), increased suicidal thoughts (especially first 1-2 weeks - monitor closely)
|
||||
\item \textbf{Drug Interactions}: Avoid other serotonergic agents, NSAIDs (increased bleeding risk)
|
||||
\item \textbf{Adherence Plan}: Set daily reminder alarm, use pill box, refill prescriptions on time
|
||||
\item \textbf{Follow-up}: Psychiatry visit week 2 (phone), week 4 (in-person), week 8, then monthly
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Response Timeline}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Week 1-2: May notice side effects before benefits, monitor suicide risk closely
|
||||
\item Week 2-4: Early improvement in sleep, appetite, energy possible
|
||||
\item Week 4-6: Mood improvement, decreased anxiety expected
|
||||
\item Week 6-8: Full therapeutic effect, reassess dose if partial response
|
||||
\item Week 12+: Continued improvement, consider maintenance therapy
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.2 Psychotherapy}
|
||||
|
||||
\textbf{Therapy Modality}: Cognitive Behavioral Therapy (CBT) for Depression
|
||||
|
||||
\textbf{Frequency}: Weekly 50-minute sessions for 12-16 weeks, then biweekly as symptoms improve
|
||||
|
||||
\textbf{Treatment Framework}:
|
||||
|
||||
\textbf{Weeks 1-4: Assessment and Behavioral Activation}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Establish therapeutic alliance and treatment goals
|
||||
\item Psychoeducation: Depression, treatment options, CBT model
|
||||
\item Activity monitoring and identifying mood-behavior connections
|
||||
\item Behavioral activation: Schedule pleasant and meaningful activities
|
||||
\item Develop daily structure and routine
|
||||
\item Suicide risk assessment and safety planning
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Weeks 5-8: Cognitive Restructuring}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Identify automatic negative thoughts
|
||||
\item Challenge cognitive distortions (all-or-nothing thinking, overgeneralization, catastrophizing)
|
||||
\item Develop balanced, realistic thoughts
|
||||
\item Address guilt and worthlessness cognitions
|
||||
\item Problem-solving skills training
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Weeks 9-12: Skill Building and Application}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Assertiveness and communication skills
|
||||
\item Interpersonal effectiveness
|
||||
\item Stress management and relaxation techniques
|
||||
\item Values clarification and goal-setting (career, relationships)
|
||||
\item Address employment/job search anxiety
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Weeks 13-16: Relapse Prevention and Maintenance}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Identify early warning signs of depression
|
||||
\item Develop personalized relapse prevention plan
|
||||
\item Review and consolidate skills learned
|
||||
\item Plan for ongoing self-care and wellness
|
||||
\item Discuss transition to maintenance phase or termination
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Specific CBT Techniques}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Thought records (identify situations, thoughts, emotions, behaviors)
|
||||
\item Behavioral experiments (test negative predictions)
|
||||
\item Activity scheduling (increase rewarding activities)
|
||||
\item Graded task assignment (break large tasks into manageable steps)
|
||||
\item Cognitive continuum (evaluate black-and-white thinking)
|
||||
\item Core belief work (address underlying schemas)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Homework Assignments}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Weekly mood and activity logs
|
||||
\item Thought records (3-column or 7-column)
|
||||
\item Behavioral activation: Complete 2-3 scheduled activities
|
||||
\item Reading: CBT self-help materials (e.g., "Feeling Good" by David Burns)
|
||||
\item Skills practice between sessions
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.3 Adjunctive Interventions}
|
||||
|
||||
\textbf{Case Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Assist with unemployment benefits and financial resources
|
||||
\item Connect with vocational rehabilitation services
|
||||
\item Coordinate care with primary care provider
|
||||
\item Insurance and medication assistance navigation
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Lifestyle Interventions}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Exercise}: Goal of 30 minutes moderate exercise 5x/week (walking, yoga, biking)
|
||||
\item \textbf{Sleep Hygiene}: Consistent sleep schedule (11 PM - 7 AM), limit screen time 1 hour before bed, avoid caffeine after 2 PM, bedroom for sleep only
|
||||
\item \textbf{Nutrition}: Regular balanced meals, minimize processed foods, stay hydrated
|
||||
\item \textbf{Substance Use}: Continue cannabis abstinence, limit alcohol to 1-2 drinks/week max
|
||||
\item \textbf{Light Exposure}: Morning sunlight or light box 30 min daily (if seasonal pattern)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Social Support Enhancement}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Increase contact with sister (supportive relationship)
|
||||
\item Consider depression support group (online or in-person)
|
||||
\item Re-engage with friend group gradually
|
||||
\item Volunteer opportunities for meaningful engagement
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Family/Collateral Sessions}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Offer to include sister in 1-2 sessions (with patient consent) for psychoeducation and support
|
||||
\item Educate family on depression, how to help, what to avoid (enabling, criticism)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 5: TREATMENT SCHEDULE =====
|
||||
\section*{5. Treatment Schedule and Timeline}
|
||||
|
||||
\subsection*{Treatment Phases}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|l|X|}
|
||||
\hline
|
||||
\textbf{Phase} & \textbf{Duration} & \textbf{Focus} \\ \hline
|
||||
Acute Treatment & Weeks 1-8 & Symptom reduction, medication titration, behavioral activation, safety \\ \hline
|
||||
Continuation & Weeks 9-16 & Cognitive restructuring, skill building, functional recovery \\ \hline
|
||||
Maintenance & Months 4-12 & Relapse prevention, sustained wellness, reduce visit frequency \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Appointment Schedule}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|l|X|}
|
||||
\hline
|
||||
\textbf{Provider} & \textbf{Frequency} & \textbf{Notes} \\ \hline
|
||||
Psychiatry & Week 2 (phone), 4, 8, then monthly & Medication management, side effect monitoring \\ \hline
|
||||
Psychotherapy (CBT) & Weekly weeks 1-12, biweekly weeks 13-16 & 50-minute sessions \\ \hline
|
||||
PHQ-9/GAD-7 Assessment & Every 2 weeks & Track symptom severity \\ \hline
|
||||
Case Management & As needed & Resources, benefits, vocational support \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Milestones and Reassessment}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Week 2}: Medication tolerance check, safety assessment, initial behavioral activation
|
||||
\item \textbf{Week 4}: PHQ-9 reassessment, medication dose adjustment if needed, CBT engagement
|
||||
\item \textbf{Week 8}: Comprehensive reassessment, PHQ-9 target $<$10, functional improvement expected
|
||||
\item \textbf{Week 12}: PHQ-9 target $<$5, relapse prevention planning initiated
|
||||
\item \textbf{Week 16}: Treatment goal review, transition to maintenance or taper frequency
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 6: MONITORING AND OUTCOMES =====
|
||||
\section*{6. Monitoring Parameters and Outcomes}
|
||||
|
||||
\subsection*{Symptom Tracking}
|
||||
|
||||
\begin{longtable}{|p{4cm}|p{2.5cm}|p{2.5cm}|p{4.5cm}|}
|
||||
\hline
|
||||
\textbf{Measure} & \textbf{Baseline} & \textbf{Target} & \textbf{Frequency} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Measure} & \textbf{Baseline} & \textbf{Target} & \textbf{Frequency} \\ \hline
|
||||
\endhead
|
||||
PHQ-9 (Depression) & 18/27 & $<$5 (remission) & Every 2 weeks \\ \hline
|
||||
GAD-7 (Anxiety) & 12/21 & $<$5 & Every 2 weeks \\ \hline
|
||||
C-SSRS (Suicide Risk) & Level 3 (passive SI) & Level 0 (no SI) & Each session initially, then monthly \\ \hline
|
||||
Sleep Quality & 4-5 hrs, fragmented & 6-7 hrs, consolidated & Weekly self-report \\ \hline
|
||||
Social Activities & 0-1/week & 3-4/week & Weekly log \\ \hline
|
||||
Exercise & 0 days/week & 5 days/week & Weekly log \\ \hline
|
||||
Therapy Homework & -- & 80\% completion & Each session \\ \hline
|
||||
Medication Adherence & -- & $>$90\% & Each psychiatry visit \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Functional Outcome Tracking}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Self-Care}: Daily routine checklist (shower, meals, sleep, medications)
|
||||
\item \textbf{Social Functioning}: Number of social interactions per week
|
||||
\item \textbf{Occupational}: Job applications submitted, interviews attended, volunteer hours
|
||||
\item \textbf{Quality of Life}: Engagement in hobbies, pleasurable activities
|
||||
\item \textbf{Overall Functioning}: GAF or WHODAS score at baseline, 8 weeks, discharge
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Safety Monitoring}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Suicidal ideation assessment at every contact (especially weeks 1-4)
|
||||
\item Medication side effects and tolerability
|
||||
\item Substance use (alcohol, cannabis) - weekly check-ins
|
||||
\item Worsening symptoms or breakthrough depression
|
||||
\item Medication adherence
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 7: CRISIS AND SAFETY PLANNING =====
|
||||
\section*{7. Crisis Management and Safety Planning}
|
||||
|
||||
\subsection*{Safety Plan (Based on Stanley-Brown Model)}
|
||||
|
||||
\textbf{Step 1: Warning Signs}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Thoughts: "I'm worthless," "Things will never get better," "I'm a burden"
|
||||
\item Feelings: Hopelessness, overwhelming sadness, numbness
|
||||
\item Behaviors: Isolating for days, not eating, excessive sleeping
|
||||
\item Situations: Financial stress, rejection, conflict with family
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Step 2: Internal Coping Strategies} (things I can do on my own)
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Go for a walk outside
|
||||
\item Listen to favorite music playlist
|
||||
\item Take a warm shower
|
||||
\item Deep breathing exercises (5-10 minutes)
|
||||
\item Read CBT thought records
|
||||
\item Write in journal
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Step 3: Social Contacts for Distraction}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Sister: [phone number]
|
||||
\item Close friend: [phone number]
|
||||
\item Former coworker: [phone number]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Step 4: People I Can Ask for Help}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Sister: [phone number] - can talk about feelings, will listen without judgment
|
||||
\item Therapist: [phone number] - call for emergency appointment
|
||||
\item Psychiatrist: [phone number] - after-hours answering service
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Step 5: Professionals and Agencies to Contact}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Therapist: [clinic phone]
|
||||
\item Psychiatrist on-call: [after-hours number]
|
||||
\item Crisis Line: 988 Suicide \& Crisis Lifeline (call or text 988)
|
||||
\item Crisis Text Line: Text HOME to 741741
|
||||
\item Local crisis center: [local crisis services phone]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Step 6: Reduce Access to Lethal Means}
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item No firearms in home
|
||||
\item Medications: Sister holds extra medication supply, patient has only 1-week supply at home
|
||||
\item Remove other potential means from immediate environment
|
||||
\end{itemize}
|
||||
|
||||
\textbf{One Thing That Is Most Important to Me}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item [e.g., "My relationship with my sister - I don't want to hurt her"]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Emergency Procedures}
|
||||
|
||||
\textbf{Patient to seek immediate care (Emergency Department or call 911) if}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Active suicidal ideation with plan and intent
|
||||
\item Unable to maintain safety despite using crisis plan
|
||||
\item Acute psychosis (hallucinations, delusions, disorganized behavior)
|
||||
\item Severe agitation or aggression toward others
|
||||
\item Substance intoxication/overdose
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Provider to intervene if}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Increased suicide risk (passive → active SI, plan development)
|
||||
\item Significant worsening of depression or emergence of psychotic symptoms
|
||||
\item Non-adherence with safety plan
|
||||
\item Relapse in substance use
|
||||
\item Actions: Increase visit frequency, consider higher level of care (IOP/PHP/inpatient), medication adjustment, collateral contact with family
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 8: PATIENT EDUCATION =====
|
||||
\section*{8. Patient Education and Psychoeducation}
|
||||
|
||||
\subsection*{Understanding Depression}
|
||||
|
||||
Education provided on:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{What is Depression}: Biological illness, not weakness or character flaw
|
||||
\item \textbf{Neurobiology}: Serotonin, norepinephrine, brain circuits involved
|
||||
\item \textbf{Course}: Episodic illness, high recurrence rate, importance of treatment adherence
|
||||
\item \textbf{Treatment}: Evidence for medication + therapy combination
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Medication Education}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item How SSRIs work (increase serotonin availability)
|
||||
\item Timeline for response (2-4 weeks initial, 6-8 weeks full effect)
|
||||
\item Common side effects and management
|
||||
\item Importance of daily adherence (not "as needed")
|
||||
\item Not addictive, but need to taper when discontinuing
|
||||
\item Maintenance treatment (continue 6-12 months after remission)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Therapy Skills and Homework}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item CBT model: Thoughts → Feelings → Behaviors (interconnected)
|
||||
\item Behavioral activation: Activity improves mood (not the reverse)
|
||||
\item Cognitive distortions: Common thinking errors in depression
|
||||
\item Thought challenging: Evidence for/against, alternative perspectives
|
||||
\item Skills practice between sessions is essential
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Self-Management Strategies}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Recognize early warning signs of depression
|
||||
\item When to call provider (worsening symptoms, suicidal thoughts)
|
||||
\item Lifestyle factors: sleep, exercise, nutrition, substance use
|
||||
\item Stress management and self-care
|
||||
\item Building and maintaining social connections
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Resources Provided}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Crisis hotline numbers (988, Crisis Text Line)
|
||||
\item CBT self-help books: "Feeling Good" by David Burns, "Mind Over Mood"
|
||||
\item Meditation apps: Headspace, Calm, Insight Timer
|
||||
\item Exercise resources: Local trails, gyms, online yoga
|
||||
\item NAMI (National Alliance on Mental Illness) support groups
|
||||
\item Depression and Bipolar Support Alliance (DBSA)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 9: FOLLOW-UP AND DISCHARGE =====
|
||||
\section*{9. Follow-Up and Discharge Planning}
|
||||
|
||||
\subsection*{Continuation and Maintenance Treatment}
|
||||
|
||||
\textbf{After Acute Treatment (if goals achieved)}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Continue medication for 6-12 months minimum after remission
|
||||
\item Taper therapy to biweekly, then monthly "booster" sessions
|
||||
\item Regular symptom monitoring (monthly PHQ-9)
|
||||
\item Psychiatry visits every 2-3 months for medication management
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Relapse Prevention}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Early Warning Signs}: [Patient-specific list from treatment]
|
||||
\item \textbf{Action Plan}: If warning signs emerge, resume weekly therapy, contact psychiatrist
|
||||
\item \textbf{Protective Factors}: Maintain exercise, sleep, social connections, continue medication
|
||||
\item \textbf{Ongoing Skills Practice}: Continue thought records, behavioral activation as needed
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Discharge Criteria}
|
||||
|
||||
Ready for discharge when:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item PHQ-9 $<$5 sustained for 4+ weeks
|
||||
\item No suicidal ideation
|
||||
\item Functional recovery (working or engaged in meaningful activities, social connections restored)
|
||||
\item Mastery of CBT skills and relapse prevention plan
|
||||
\item Stable on medication regimen
|
||||
\item Patient and provider agree discharge is appropriate
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Discharge Recommendations}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Continue antidepressant for 6-12 months, then discuss tapering with psychiatrist
|
||||
\item Monthly "check-in" sessions available if needed
|
||||
\item Return to treatment if early warning signs emerge
|
||||
\item Continue healthy lifestyle practices
|
||||
\item Stay connected with support system
|
||||
\item Annual depression screening with primary care provider
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 10: INFORMED CONSENT =====
|
||||
\section*{10. Informed Consent and Collaboration}
|
||||
|
||||
\subsection*{Treatment Consent}
|
||||
|
||||
The following have been discussed with the patient:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Diagnosis, symptoms, and prognosis
|
||||
\item Treatment options (medication, therapy, combination, no treatment)
|
||||
\item Risks and benefits of recommended treatment
|
||||
\item Expected timeline for improvement
|
||||
\item Potential side effects of medication
|
||||
\item Alternatives to proposed treatment
|
||||
\item Importance of adherence and therapy homework
|
||||
\item Right to refuse or discontinue treatment
|
||||
\item Limits of confidentiality (harm to self/others, abuse)
|
||||
\end{itemize}
|
||||
|
||||
Patient demonstrates understanding and agrees to treatment plan. Questions answered satisfactorily. Patient has opportunity for shared decision-making and treatment preferences incorporated.
|
||||
|
||||
\subsection*{Collaborative Treatment Agreement}
|
||||
|
||||
\textbf{Provider Responsibilities}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Provide evidence-based treatment
|
||||
\item Monitor progress and adjust treatment as needed
|
||||
\item Maintain availability for emergencies (or provide backup coverage)
|
||||
\item Respect patient autonomy and preferences
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Patient Responsibilities}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Attend scheduled appointments
|
||||
\item Take medications as prescribed
|
||||
\item Complete therapy homework
|
||||
\item Communicate openly about symptoms and concerns
|
||||
\item Contact provider if symptoms worsen or suicidal thoughts emerge
|
||||
\item Follow safety plan
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 11: SIGNATURES =====
|
||||
\vspace{2em}
|
||||
|
||||
\section*{11. Provider Signature and Attestation}
|
||||
|
||||
I have reviewed this treatment plan with the patient. The patient demonstrates understanding of the diagnosis, treatment recommendations, risks and benefits, and alternatives. The patient has been involved in shared decision-making. Safety planning has been completed. The patient agrees to this treatment plan.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Provider Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Provider Name/Credentials: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\[2em]
|
||||
\end{tabular}
|
||||
|
||||
\subsection*{Patient Acknowledgment}
|
||||
|
||||
I have reviewed this treatment plan with my mental health provider. I understand my diagnosis, treatment goals, and the recommended interventions. My questions have been answered. I agree to participate in this treatment plan and will contact my provider if I have concerns or my symptoms worsen.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Patient Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\
|
||||
\end{tabular}
|
||||
|
||||
\vspace{2em}
|
||||
\begin{center}
|
||||
\rule{\textwidth}{1pt}\\
|
||||
\textbf{End of Mental Health Treatment Plan}\\
|
||||
This document contains confidential patient information protected by HIPAA and 42 CFR Part 2.
|
||||
\end{center}
|
||||
|
||||
\end{document}
|
||||
|
||||
% ========== NOTES FOR USERS ==========
|
||||
%
|
||||
% CUSTOMIZATION:
|
||||
% - Replace all bracketed placeholders with patient-specific information
|
||||
% - Adjust CBT framework based on presenting problem (can use DBT, ACT, IPT instead)
|
||||
% - Modify safety plan collaboratively with patient
|
||||
% - Select appropriate medications based on diagnosis and patient factors
|
||||
%
|
||||
% IMPORTANT:
|
||||
% - Complete thorough suicide risk assessment
|
||||
% - Document safety planning
|
||||
% - Ensure crisis resources are accurate and accessible
|
||||
% - Maintain 42 CFR Part 2 confidentiality for substance use information
|
||||
%
|
||||
% COMPILATION:
|
||||
% pdflatex mental_health_treatment_plan.tex
|
||||
|
||||
193
skills/treatment-plans/assets/one_page_treatment_plan.tex
Normal file
193
skills/treatment-plans/assets/one_page_treatment_plan.tex
Normal file
@@ -0,0 +1,193 @@
|
||||
% One-Page Treatment Plan Template
|
||||
% Concise, clinician-focused treatment recommendation
|
||||
% Modeled after precision oncology reports and clinical decision support cards
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[10pt,letterpaper]{article}
|
||||
|
||||
% Minimal packages for clean, dense layout
|
||||
\usepackage[top=0.5in,bottom=0.5in,left=0.6in,right=0.6in]{geometry}
|
||||
\usepackage{amsmath,amssymb}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{graphicx}
|
||||
\usepackage{array}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{tabularx}
|
||||
\usepackage[most]{tcolorbox}
|
||||
\usepackage{multicol}
|
||||
|
||||
% Compact spacing
|
||||
\setlist{nosep,leftmargin=*,itemsep=0pt,topsep=2pt}
|
||||
\setlength{\parindent}{0pt}
|
||||
\setlength{\parskip}{4pt}
|
||||
|
||||
% No page numbers for single page
|
||||
\pagestyle{empty}
|
||||
|
||||
% Section formatting - compact
|
||||
\usepackage{titlesec}
|
||||
\titlespacing*{\section}{0pt}{8pt}{4pt}
|
||||
\titlespacing*{\subsection}{0pt}{6pt}{3pt}
|
||||
\titleformat{\section}{\normalsize\bfseries\sffamily}{\thesection}{0em}{}
|
||||
\titleformat{\subsection}{\small\bfseries\sffamily}{\thesubsection}{0em}{}
|
||||
|
||||
% Color scheme
|
||||
\definecolor{headerblue}{RGB}{0,102,153}
|
||||
\definecolor{lightgray}{RGB}{240,240,240}
|
||||
\definecolor{darkgray}{RGB}{80,80,80}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% ========== TITLE ==========
|
||||
\begin{center}
|
||||
{\small\textit{PRECISION MEDICINE / CLINICAL RECOMMENDATION}}\\[2pt]
|
||||
{\Large\bfseries\sffamily [Treatment Type]}\\[1pt]
|
||||
{\normalsize\textit{[Condition/Disease Name]}}
|
||||
\end{center}
|
||||
|
||||
\vspace{-8pt}
|
||||
|
||||
% ========== PATIENT/CASE INFO BOX ==========
|
||||
\begin{tcolorbox}[
|
||||
colback=lightgray,
|
||||
colframe=headerblue,
|
||||
boxrule=0.5pt,
|
||||
arc=2pt,
|
||||
left=4pt,right=4pt,top=3pt,bottom=3pt,
|
||||
fontupper=\small
|
||||
]
|
||||
\textbf{Patient ID:} [De-identified ID] \hfill \textbf{Date:} \today\\
|
||||
\textbf{Diagnosis:} [Primary diagnosis + ICD-10] \hfill \textbf{Stage/Grade:} [If applicable]\\
|
||||
\textbf{Age/Sex:} [Age range, sex] \hfill \textbf{Molecular Profile:} [Key biomarkers or cluster, if applicable]
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{4pt}
|
||||
|
||||
% ========== TWO-COLUMN LAYOUT FOR EFFICIENCY ==========
|
||||
\begin{multicols}{2}
|
||||
|
||||
% ========== LEFT COLUMN ==========
|
||||
|
||||
\section*{TARGET PATIENT POPULATION}
|
||||
{\small
|
||||
\textbf{Number of Patients:} [N (\% of cohort)]\\
|
||||
\textbf{Key Features:} [Brief demographic or clinical features]\\
|
||||
\textbf{Inclusion Criteria:} [1-2 key criteria]
|
||||
}
|
||||
|
||||
\section*{PRIMARY TREATMENT REGIMEN}
|
||||
{\small
|
||||
\begin{enumerate}[leftmargin=12pt]
|
||||
\item \textbf{[Intervention 1]:} [Specific details]
|
||||
\begin{itemize}
|
||||
\item Dose: [specific dosing]
|
||||
\item Frequency: [schedule]
|
||||
\item Duration: [timeframe]
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{[Intervention 2]:} [Specific details]
|
||||
\begin{itemize}
|
||||
\item [Key parameters]
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{[Intervention 3]:} [Optional, if needed]
|
||||
\begin{itemize}
|
||||
\item [Key parameters]
|
||||
\end{itemize}
|
||||
\end{enumerate}
|
||||
}
|
||||
|
||||
\section*{SUPPORTIVE CARE}
|
||||
{\small
|
||||
\begin{itemize}
|
||||
\item \textbf{[Supportive Med 1]:} [dose/frequency]
|
||||
\item \textbf{[Supportive Med 2]:} [dose/frequency]
|
||||
\item \textbf{[Other support]:} [brief description]
|
||||
\end{itemize}
|
||||
}
|
||||
|
||||
\section*{RATIONALE}
|
||||
{\small
|
||||
[1-3 sentences explaining why this regimen is appropriate for this patient. Include key pathophysiology, guideline alignment, or molecular rationale if applicable.]
|
||||
}
|
||||
|
||||
\columnbreak
|
||||
|
||||
% ========== RIGHT COLUMN ==========
|
||||
|
||||
\section*{MOLECULAR TARGETS / RISK FACTORS}
|
||||
{\small
|
||||
\begin{itemize}
|
||||
\item \textbf{[Target/Factor 1]:} [Value/status]
|
||||
\item \textbf{[Target/Factor 2]:} [Value/status]
|
||||
\item \textbf{[Target/Factor 3]:} [Value/status]
|
||||
\end{itemize}
|
||||
}
|
||||
|
||||
\section*{EVIDENCE LEVEL}
|
||||
{\small
|
||||
\textbf{[Level designation - e.g., Level 1, FDA approved]}\\
|
||||
\textbf{Supporting Evidence:} [Guideline name/year or key trial]\\
|
||||
\textbf{References:} [1-2 key citations in abbreviated format]
|
||||
}
|
||||
|
||||
\section*{MONITORING REQUIREMENTS}
|
||||
{\small
|
||||
\begin{tabular}{@{}ll@{}}
|
||||
\textbf{Parameter} & \textbf{Frequency} \\
|
||||
\hline
|
||||
[Lab/vital 1] & [e.g., Weekly x 4 weeks] \\
|
||||
[Lab/vital 2] & [e.g., Monthly x 3 months] \\
|
||||
[Lab/vital 3] & [e.g., Every 3 months] \\
|
||||
[Assessment tool] & [e.g., Baseline, 3 mo, 6 mo] \\
|
||||
\end{tabular}
|
||||
}
|
||||
|
||||
\section*{EXPECTED CLINICAL BENEFIT}
|
||||
{\small
|
||||
\textbf{Primary Outcome:} [e.g., Median OS 20.9 months]\\
|
||||
\textbf{Timeline:} [e.g., Response assessment at 12 weeks]\\
|
||||
\textbf{Success Criteria:} [Specific metrics for goal achievement]
|
||||
}
|
||||
|
||||
\section*{CRITICAL DECISION POINTS}
|
||||
{\small
|
||||
\begin{itemize}
|
||||
\item \textbf{Hold treatment if:} [Specific criteria]
|
||||
\item \textbf{Dose modify for:} [Specific criteria]
|
||||
\item \textbf{Discontinue if:} [Specific criteria]
|
||||
\end{itemize}
|
||||
}
|
||||
|
||||
\end{multicols}
|
||||
|
||||
\vspace{4pt}
|
||||
|
||||
% ========== BOTTOM SECTION - FULL WIDTH ==========
|
||||
\begin{tcolorbox}[
|
||||
colback=yellow!10,
|
||||
colframe=red!60!black,
|
||||
boxrule=0.8pt,
|
||||
arc=2pt,
|
||||
left=4pt,right=4pt,top=3pt,bottom=3pt,
|
||||
fontupper=\small\bfseries
|
||||
]
|
||||
\textbf{EMERGENCY CONTACTS / URGENT CONCERNS:} \\
|
||||
{\small\normalfont
|
||||
Call [clinic/provider] immediately for: [List 2-3 red flag symptoms]. \\
|
||||
Emergency: 911 | Clinic: [phone] | After-hours: [phone] | Pharmacy: [phone]
|
||||
}
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{6pt}
|
||||
|
||||
{\footnotesize\textit{
|
||||
Prepared by: [Provider name, credentials] | Plan created: \today | Next review: [date] \\
|
||||
HIPAA Notice: This document contains de-identified patient information per Safe Harbor standards.
|
||||
}}
|
||||
|
||||
\end{document}
|
||||
|
||||
799
skills/treatment-plans/assets/pain_management_plan.tex
Normal file
799
skills/treatment-plans/assets/pain_management_plan.tex
Normal file
@@ -0,0 +1,799 @@
|
||||
% Pain Management Plan Template
|
||||
% For acute and chronic pain treatment
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[11pt,letterpaper]{article}
|
||||
|
||||
% Packages
|
||||
\usepackage[top=1in,bottom=1in,left=1in,right=1in]{geometry}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{array}
|
||||
\usepackage{longtable}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{lastpage}
|
||||
\usepackage{tabularx}
|
||||
\usepackage[most]{tcolorbox}
|
||||
|
||||
% Header and footer
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\lhead{Pain Management Plan}
|
||||
\rhead{Page \thepage\ of \pageref{LastPage}}
|
||||
\lfoot{Date Created: \today}
|
||||
\rfoot{Confidential Patient Information}
|
||||
|
||||
% Title formatting
|
||||
\usepackage{titlesec}
|
||||
\titleformat{\section}{\large\bfseries}{\thesection}{1em}{}
|
||||
\titleformat{\subsection}{\normalsize\bfseries}{\thesubsection}{1em}{}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% Title
|
||||
\begin{center}
|
||||
{\Large\bfseries PAIN MANAGEMENT PLAN}\\[0.5em]
|
||||
{\large Comprehensive Multimodal Pain Treatment}\\[0.5em]
|
||||
\rule{\textwidth}{1pt}
|
||||
\end{center}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== TREATMENT PLAN HIGHLIGHTS (Foundation Medicine Model) =====
|
||||
\begin{tcolorbox}[colback=yellow!10!white,colframe=yellow!75!black,title=\textbf{TREATMENT PLAN HIGHLIGHTS},fonttitle=\bfseries\large]
|
||||
|
||||
\textbf{Pain Diagnosis:} [Primary pain condition - e.g., Chronic low back pain, nociceptive/neuropathic mixed]
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Primary Treatment Goals:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item [Goal 1 - e.g., Reduce pain from 8/10 to $<$5/10 within 8 weeks]
|
||||
\item [Goal 2 - e.g., Return to work with accommodations within 12 weeks]
|
||||
\item [Goal 3 - e.g., Improve physical function - walk 30 minutes without significant pain]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Main Interventions:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Multimodal Pharmacotherapy:} [Medications - e.g., Acetaminophen, duloxetine, topical lidocaine]
|
||||
\item \textit{Physical Interventions:} [Therapies - e.g., PT 2x/week, core strengthening, heat/ice]
|
||||
\item \textit{Behavioral:} [Approaches - e.g., CBT for pain, relaxation techniques, activity pacing]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Timeline:} [Phases - e.g., Intensive treatment (8 weeks), Optimization (12 weeks), Long-term management]
|
||||
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== SECTION 1: PATIENT AND PAIN INFORMATION =====
|
||||
\section*{1. Patient Information and Pain Assessment}
|
||||
|
||||
\textbf{HIPAA Notice}: De-identify all protected health information before sharing.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Patient ID} & [De-identified code, e.g., PM-001] \\ \hline
|
||||
\textbf{Age Range} & [e.g., 45-50 years] \\ \hline
|
||||
\textbf{Sex} & [Male/Female/Other] \\ \hline
|
||||
\textbf{Date of Plan} & [Month/Year only] \\ \hline
|
||||
\textbf{Pain Specialist} & [Name, MD, Credentials] \\ \hline
|
||||
\textbf{Referring Provider} & [Name, MD/NP/PA] \\ \hline
|
||||
\textbf{Facility} & [Pain clinic/hospital name] \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\subsection*{Pain Characteristics}
|
||||
|
||||
\textbf{Pain Type}: [e.g., Chronic low back pain] ☐ Acute ☑ Chronic
|
||||
|
||||
\textbf{Primary Pain Diagnosis}: [e.g., Chronic lumbar radiculopathy] (ICD-10: [M54.16])
|
||||
|
||||
\textbf{Secondary Pain Diagnoses}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item [e.g., Lumbar spinal stenosis] (ICD-10: [M48.06])
|
||||
\item [e.g., Degenerative disc disease L4-L5] (ICD-10: [M51.36])
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Duration}: [e.g., 3 years of chronic pain, worsening past 6 months]
|
||||
|
||||
\textbf{Pain Location}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Primary}: Lower back (lumbar region L4-L5)
|
||||
\item \textbf{Radiation}: Right leg, posterior thigh to calf (sciatic distribution)
|
||||
\item \textbf{Secondary}: [Other pain sites if applicable]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Pain Quality}: [e.g., Sharp, shooting pain in leg; dull ache in back]
|
||||
|
||||
\textbf{Pain Intensity}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Current}: [e.g., 7/10 numeric rating scale (NRS)]
|
||||
\item \textbf{Average (past week)}: [e.g., 6/10]
|
||||
\item \textbf{Worst}: [e.g., 9/10]
|
||||
\item \textbf{Best}: [e.g., 4/10 with rest]
|
||||
\item \textbf{At night}: [e.g., 6/10, disrupts sleep]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Temporal Pattern}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ☐ Constant ☑ Intermittent ☐ Episodic
|
||||
\item \textbf{Frequency}: Daily, worse with activity
|
||||
\item \textbf{Duration of episodes}: Varies, 2-6 hours of severe pain
|
||||
\item \textbf{Breakthrough pain}: [e.g., Yes, with bending, lifting, prolonged sitting]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Aggravating Factors}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Prolonged sitting ($>$30 minutes)
|
||||
\item Bending forward
|
||||
\item Lifting objects $>$10 lbs
|
||||
\item Prolonged standing
|
||||
\item Coughing, sneezing (increases radicular pain)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Alleviating Factors}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Lying supine with knees elevated
|
||||
\item Heat application to lower back
|
||||
\item Walking short distances (5-10 minutes)
|
||||
\item Current pain medications (partial relief)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Pain Impact Assessment}
|
||||
|
||||
\textbf{Functional Interference} (Brief Pain Inventory - BPI):
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|c|X|}
|
||||
\hline
|
||||
\textbf{Domain} & \textbf{Score (0-10)} & \textbf{Description} \\ \hline
|
||||
General Activity & 7/10 & Significantly limited household tasks \\ \hline
|
||||
Mood & 6/10 & Frustration, irritability, mild depression \\ \hline
|
||||
Walking Ability & 8/10 & Can walk only 5-10 minutes before pain \\ \hline
|
||||
Work & 9/10 & Unable to work (construction job), on disability \\ \hline
|
||||
Relationships & 5/10 & Decreased social engagement \\ \hline
|
||||
Sleep & 7/10 & Difficulty falling asleep, awakens with pain \\ \hline
|
||||
Enjoyment of Life & 8/10 & Cannot participate in hobbies (fishing, gardening) \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\textbf{Quality of Life Impact}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Unable to work for 1 year
|
||||
\item Difficulty with ADLs (bathing, dressing due to bending limitations)
|
||||
\item Social isolation, stopped attending family events
|
||||
\item Stopped recreational activities (fishing, yard work)
|
||||
\item Relationship strain with spouse
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Psychological Impact}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Depression Screening} (PHQ-9): [e.g., 12/27 - Moderate depression]
|
||||
\item \textbf{Anxiety Screening} (GAD-7): [e.g., 10/21 - Moderate anxiety]
|
||||
\item \textbf{Pain Catastrophizing}: [e.g., Moderate - frequent thoughts that pain won't improve]
|
||||
\item \textbf{Sleep Disturbance}: [e.g., 5-6 hours/night, poor quality]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Previous Pain Treatments}
|
||||
|
||||
\textbf{Medications Tried}:
|
||||
\begin{longtable}{|p{3cm}|p{2.5cm}|p{7.5cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Duration} & \textbf{Response} \\ \hline
|
||||
NSAIDs (ibuprofen) & 2 years & Partial relief initially, GI upset, ineffective now \\ \hline
|
||||
Acetaminophen & 1 year & Minimal benefit \\ \hline
|
||||
Cyclobenzaprine & 6 months & Sedation, minimal pain relief, discontinued \\ \hline
|
||||
Gabapentin & 3 months & Tried up to 1800mg/day, minimal benefit, dizziness \\ \hline
|
||||
Tramadol & 1 year & Partial relief, nausea, stopped working \\ \hline
|
||||
[List others] & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Interventional Procedures}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Lumbar epidural steroid injection (ESI) x2 - Last [6 months ago], temporary relief (3-4 weeks)
|
||||
\item Physical therapy: 3 months, minimal sustained benefit
|
||||
\item Chiropractic care: 6 months, temporary relief only
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Non-pharmacological}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Physical therapy, home exercise program (partial compliance)
|
||||
\item Heat/ice application
|
||||
\item TENS unit (limited benefit)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Medical and Surgical History}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Relevant Comorbidities}: Hypertension, GERD, obesity (BMI 33)
|
||||
\item \textbf{Previous Surgeries}: None on spine
|
||||
\item \textbf{Imaging}:
|
||||
\begin{itemize}
|
||||
\item Lumbar MRI [6 months ago]: L4-L5 disc herniation, moderate central stenosis, right foraminal narrowing
|
||||
\item No surgical candidacy per neurosurgery consultation
|
||||
\end{itemize}
|
||||
\item \textbf{Current Medications}: Lisinopril 20mg daily, omeprazole 20mg daily
|
||||
\item \textbf{Allergies}: NKDA
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Substance Use and Risk Assessment}
|
||||
|
||||
\textbf{Alcohol}: [e.g., Social use, 2-3 drinks/week]
|
||||
|
||||
\textbf{Tobacco}: [e.g., 10 pack-year history, quit 2 years ago]
|
||||
|
||||
\textbf{Illicit Drugs}: [e.g., Denies current or past use]
|
||||
|
||||
\textbf{Opioid Risk Tool (ORT) Score}: [e.g., 3 points - Moderate risk]
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Family history of substance abuse: Yes (1 point)
|
||||
\item Personal history of substance abuse: No
|
||||
\item Age 16-45: No (patient is 45-50)
|
||||
\item History of preadolescent sexual abuse: No
|
||||
\item Psychological disease: Depression (2 points)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Urine Drug Screen (UDS)}: [e.g., Negative - Baseline before starting controlled substances]
|
||||
|
||||
\textbf{Prescription Drug Monitoring Program (PDMP)}: [e.g., Checked - No other controlled substance prescriptions]
|
||||
|
||||
% ===== SECTION 2: PAIN MANAGEMENT GOALS =====
|
||||
\section*{2. Pain Management Goals (SMART Format)}
|
||||
|
||||
\textbf{Realistic Expectations Discussed}: Complete pain elimination unlikely; goal is meaningful pain reduction and improved function.
|
||||
|
||||
\subsection*{2.1 Short-Term Goals (4-8 weeks)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Pain Intensity}: Reduce average pain from 6-7/10 to 4-5/10 using multimodal analgesia within 6 weeks.
|
||||
|
||||
\item \textbf{Functional Improvement}: Increase walking tolerance from 5-10 minutes to 20-30 minutes within 8 weeks.
|
||||
|
||||
\item \textbf{Sleep}: Improve sleep quality from 5-6 hours to 7 hours per night with fewer pain-related awakenings within 4 weeks.
|
||||
|
||||
\item \textbf{Medication Optimization}: Establish effective multimodal regimen with minimal side effects within 4 weeks.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{2.2 Long-Term Goals (3-6 months)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Pain Reduction}: Achieve average pain level of 3-4/10, allowing engagement in daily activities within 3 months.
|
||||
|
||||
\item \textbf{Return to Work}: Explore modified duty or vocational rehabilitation with goal of returning to some form of employment within 6 months.
|
||||
|
||||
\item \textbf{Functional Activities}: Resume light recreational activities (fishing, light gardening with modifications) within 4 months.
|
||||
|
||||
\item \textbf{Psychological Well-being}: Reduce depression (PHQ-9 $<$10) and anxiety (GAD-7 $<$8) through pain relief and CBT within 3 months.
|
||||
|
||||
\item \textbf{Reduced Pain Interference}: Improve BPI interference scores by 30-40\% across all domains within 6 months.
|
||||
|
||||
\item \textbf{Opioid Reduction}: If opioids initiated, taper to lowest effective dose or discontinue if alternative strategies successful.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{2.3 Patient-Identified Goals}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Priority 1}: "I want to be able to play with my grandkids without being in agony"
|
||||
\item \textbf{Priority 2}: "I want to sleep through the night"
|
||||
\item \textbf{Priority 3}: "I want to do some kind of work, even if not my old job"
|
||||
\item \textbf{Priority 4}: "I don't want to be on pain pills forever"
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 3: MULTIMODAL TREATMENT PLAN =====
|
||||
\section*{3. Comprehensive Multimodal Treatment Plan}
|
||||
|
||||
\textbf{Approach}: Opioid-sparing multimodal analgesia with combination pharmacologic, interventional, physical, and psychological therapies.
|
||||
|
||||
\subsection*{3.1 Pharmacological Management}
|
||||
|
||||
\textbf{First-Line Non-Opioid Analgesics}:
|
||||
|
||||
\begin{longtable}{|p{3cm}|p{2cm}|p{2cm}|p{6.5cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Rationale \& Instructions} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Rationale \& Instructions} \\ \hline
|
||||
\endhead
|
||||
|
||||
Duloxetine (Cymbalta) & 30mg, titrate to 60mg & Daily & \textbf{Rationale}: SNRI approved for chronic MSK pain, also treats comorbid depression. \textbf{Start}: 30mg daily x 1 week, then 60mg daily. \textbf{Benefit}: Pain reduction + mood improvement. \textbf{Monitor}: Nausea (take with food), BP, suicidal ideation first weeks. \\ \hline
|
||||
|
||||
Meloxicam & 15mg & Daily & \textbf{Rationale}: NSAID for inflammatory component. \textbf{Instructions}: Take with food. \textbf{Monitor}: GI symptoms (on PPI already), renal function, BP. \textbf{Duration}: Trial 4-8 weeks, reassess if benefit vs. risk. \\ \hline
|
||||
|
||||
Acetaminophen ER & 1300mg & TID (scheduled) & \textbf{Rationale}: Baseline analgesic, opioid-sparing. \textbf{Max}: 4000mg/day. Safe with liver function normal. Scheduled, not PRN for chronic pain. \\ \hline
|
||||
|
||||
Tizanidine & 2-4mg & QHS & \textbf{Rationale}: Muscle relaxant for muscle spasm component. \textbf{Start}: 2mg QHS, may increase to 4mg. \textbf{SE}: Sedation (beneficial for sleep), dry mouth. \textbf{Monitor}: BP (can lower), LFTs. \\ \hline
|
||||
|
||||
[Add as needed] & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Adjuvant Analgesics} (If first-line insufficient):
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Pregabalin (Lyrica)}: If neuropathic component predominates
|
||||
\begin{itemize}
|
||||
\item Start 75mg BID, titrate to 150mg BID over 1-2 weeks
|
||||
\item Monitor: Dizziness, sedation, weight gain, peripheral edema
|
||||
\item More effective than gabapentin, better tolerability for many patients
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Topical Therapies}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Diclofenac gel 1\%}: Apply to lower back QID (NSAID, local effect)
|
||||
\item \textbf{Lidocaine patches 5\%}: Apply to painful area up to 12 hours daily
|
||||
\item \textbf{Compounded creams}: [If appropriate - ketoprofen/baclofen/cyclobenzaprine cream]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Opioid Therapy} (If conservative measures inadequate):
|
||||
|
||||
\textit{Note: Opioids considered only after multimodal non-opioid therapies trialed. CDC guidelines followed.}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Indication}: Severe functional impairment despite aggressive non-opioid multimodal therapy
|
||||
\item \textbf{Risk-Benefit Discussion}: Documented - risks (dependence, tolerance, side effects, overdose) vs. benefits (functional improvement)
|
||||
\item \textbf{Informed Consent}: Opioid treatment agreement signed
|
||||
\item \textbf{Starting Opioid}: [e.g., Oxycodone 5mg Q6H PRN] - Lowest effective dose, short-acting initially
|
||||
\item \textbf{Morphine Milligram Equivalent (MME)}: Start $<$50 MME/day, avoid $>$90 MME/day if possible
|
||||
\item \textbf{Monitoring Plan}:
|
||||
\begin{itemize}
|
||||
\item UDS every 3-6 months
|
||||
\item PDMP check every prescription
|
||||
\item Reassess pain and function every 1-3 months
|
||||
\item Naloxone co-prescribed for overdose reversal
|
||||
\item Pain contract/opioid agreement
|
||||
\end{itemize}
|
||||
\item \textbf{Taper Plan}: If goals not met or risks outweigh benefits, slow taper (10-25\% per week to month)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{3.2 Interventional Pain Procedures}
|
||||
|
||||
\textbf{Recommended Procedures}:
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Lumbar Epidural Steroid Injection (ESI)} - Repeat series
|
||||
\begin{itemize}
|
||||
\item \textbf{Indication}: Radicular pain from disc herniation/stenosis
|
||||
\item \textbf{Approach}: Transforaminal at L4-L5 right (fluoroscopy-guided)
|
||||
\item \textbf{Timing}: Can repeat if previous 3-4 week relief, up to 3-4 injections/year
|
||||
\item \textbf{Expected Benefit}: 50-70\% experience significant short-term relief
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Medial Branch Blocks (MBB)} - Diagnostic
|
||||
\begin{itemize}
|
||||
\item \textbf{Indication}: Assess facet joint contribution to pain
|
||||
\item \textbf{Target}: L3-L4, L4-L5 facets bilaterally
|
||||
\item \textbf{Next Step}: If $>$50\% relief x2 blocks, proceed to radiofrequency ablation (RFA)
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Radiofrequency Ablation (RFA)} - If MBB positive
|
||||
\begin{itemize}
|
||||
\item \textbf{Indication}: Facet-mediated pain confirmed by diagnostic blocks
|
||||
\item \textbf{Expected Duration}: 6-12 months of relief
|
||||
\item \textbf{Repeatable}: Can repeat when pain returns
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Spinal Cord Stimulation (SCS)} - If refractory
|
||||
\begin{itemize}
|
||||
\item \textbf{Indication}: Failed conservative management, not surgical candidate
|
||||
\item \textbf{Trial First}: Percutaneous trial x 5-7 days
|
||||
\item \textbf{Permanent Implant}: If trial successful ($>$50\% pain relief, functional improvement)
|
||||
\item \textbf{Success Rate}: 50-60\% achieve sustained benefit
|
||||
\end{itemize}
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Procedure Timeline}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Month 1: ESI series (up to 3 injections, 2 weeks apart)
|
||||
\item Month 2: Evaluate ESI response, if inadequate → MBB diagnostic blocks
|
||||
\item Month 3: If MBB positive ($>$50\% relief) → RFA
|
||||
\item Month 4-6: Reassess, if still refractory → consider SCS trial
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{3.3 Physical and Rehabilitation Therapies}
|
||||
|
||||
\textbf{Physical Therapy} (Comprehensive program):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Frequency}: 2-3x/week x 8-12 weeks
|
||||
\item \textbf{Focus Areas}:
|
||||
\begin{itemize}
|
||||
\item Core strengthening (abdominals, paraspinals)
|
||||
\item Hip and leg strengthening (reduce spinal load)
|
||||
\item Flexibility and stretching (hamstrings, hip flexors)
|
||||
\item Posture and body mechanics training
|
||||
\item Aerobic conditioning (aquatic therapy, stationary bike)
|
||||
\end{itemize}
|
||||
\item \textbf{Manual Therapy}: Soft tissue mobilization, joint mobilization
|
||||
\item \textbf{Modalities}: Heat, ice, TENS as adjuncts
|
||||
\item \textbf{Functional Training}: Sit-to-stand, lifting mechanics, ADL adaptations
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Home Exercise Program}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Daily core exercises (planks, bird-dogs, bridges)
|
||||
\item Stretching routine (30 min daily)
|
||||
\item Walking program: Start 10 min 2x/day, gradually increase to 30 min continuous
|
||||
\item Aquatic exercise if accessible (lower impact)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Activity Modifications}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Avoid prolonged sitting ($>$30 min without breaks)
|
||||
\item Lifting restrictions: No lifting $>$20 lbs, use proper mechanics
|
||||
\item Ergonomic adjustments: Lumbar support, standing desk option
|
||||
\item Pacing strategies: Alternate activity with rest
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Weight Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Current BMI}: 33 (obese)
|
||||
\item \textbf{Goal}: 10\% weight loss (reduce spinal loading)
|
||||
\item \textbf{Referral}: Registered dietitian for nutrition counseling
|
||||
\item \textbf{Exercise}: Low-impact aerobic activity as tolerated
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{3.4 Psychological and Behavioral Interventions}
|
||||
|
||||
\textbf{Cognitive Behavioral Therapy for Chronic Pain (CBT-CP)}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Frequency}: Weekly 50-min sessions x 8-12 weeks
|
||||
\item \textbf{Therapist}: Pain psychologist or licensed therapist trained in CBT-CP
|
||||
\item \textbf{Components}:
|
||||
\begin{itemize}
|
||||
\item Pain education and reconceptualization
|
||||
\item Cognitive restructuring (address catastrophizing, all-or-nothing thinking)
|
||||
\item Activity pacing and graded exposure
|
||||
\item Relaxation techniques (progressive muscle relaxation, diaphragmatic breathing)
|
||||
\item Sleep hygiene
|
||||
\item Stress management
|
||||
\item Goal-setting and problem-solving
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Mindfulness-Based Stress Reduction (MBSR)}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item 8-week program, group format
|
||||
\item Meditation, body scanning, mindful movement
|
||||
\item Reduce pain catastrophizing and improve pain acceptance
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Acceptance and Commitment Therapy (ACT)}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Alternative to CBT if patient prefers
|
||||
\item Focus on acceptance, values-based living despite pain
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Sleep Hygiene and Sleep Optimization}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Regular sleep schedule (11 PM - 6 AM)
|
||||
\item Sleep environment optimization
|
||||
\item Avoid screens 1 hour before bed
|
||||
\item Consider trazodone 50mg QHS if sleep remains impaired (dual benefit: antidepressant + sleep aid)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Depression and Anxiety Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Duloxetine addresses both pain and depression
|
||||
\item Consider additional therapy if PHQ-9/GAD-7 not improving
|
||||
\item Psychiatry referral if severe or refractory
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{3.5 Complementary and Alternative Therapies}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Acupuncture}: Trial 8-10 sessions (evidence for chronic low back pain)
|
||||
\item \textbf{Massage Therapy}: 1-2x/week for muscle tension, relaxation
|
||||
\item \textbf{Yoga or Tai Chi}: Gentle movement, mind-body connection
|
||||
\item \textbf{Chiropractic Care}: Patient had some benefit previously, can continue if helpful
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 4: MONITORING AND REASSESSMENT =====
|
||||
\section*{4. Monitoring Plan and Outcome Tracking}
|
||||
|
||||
\subsection*{4.1 Regular Monitoring}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|c|X|}
|
||||
\hline
|
||||
\textbf{Parameter} & \textbf{Frequency} & \textbf{Method} \\ \hline
|
||||
Pain Intensity (NRS) & Daily (patient log) & 0-10 scale: average, worst, least daily \\ \hline
|
||||
Functional Interference (BPI) & Monthly & Brief Pain Inventory - 7 interference items \\ \hline
|
||||
Opioid Adherence (if prescribed) & Every visit & Pill counts, PDMP, UDS \\ \hline
|
||||
Medication Side Effects & Every visit & Systematic review \\ \hline
|
||||
Depression (PHQ-9) & Monthly & 9-item questionnaire \\ \hline
|
||||
Anxiety (GAD-7) & Monthly & 7-item questionnaire \\ \hline
|
||||
Sleep Quality & Weekly (patient log) & Hours slept, quality rating \\ \hline
|
||||
Physical Activity & Weekly (patient log) & Minutes walked, exercise completed \\ \hline
|
||||
Work Status & Monthly & Hours worked, restrictions \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{4.2 Follow-Up Schedule}
|
||||
|
||||
\begin{longtable}{|l|l|X|}
|
||||
\hline
|
||||
\textbf{Timeframe} & \textbf{Provider} & \textbf{Purpose} \\ \hline
|
||||
Week 2 & Pain clinic (phone) & Medication tolerance check, early side effects \\ \hline
|
||||
Week 4 & Pain specialist & Medication adjustment, assess early response, plan interventions \\ \hline
|
||||
Week 8 & Pain specialist & Comprehensive reassessment, BPI, goal progress review \\ \hline
|
||||
Month 3 & Pain specialist & Evaluate treatment response, modify plan if needed \\ \hline
|
||||
Month 6 & Pain specialist & Long-term goal assessment, maintenance planning \\ \hline
|
||||
Ongoing & Every 1-3 months & Chronic pain management, medication refills (if opioids: monthly) \\ \hline
|
||||
Physical Therapy & 2-3x/week x 8-12 weeks & See PT plan \\ \hline
|
||||
Psychology (CBT) & Weekly x 8-12 weeks & See psychological interventions \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{4.3 Treatment Response Criteria}
|
||||
|
||||
\textbf{Success Criteria} (Re-evaluate at 3 months):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Pain reduction $\geq$30\% (clinically meaningful)
|
||||
\item Functional improvement: BPI interference reduced $\geq$30\%
|
||||
\item Improved quality of life: Return to valued activities
|
||||
\item Acceptable side effect profile
|
||||
\end{itemize}
|
||||
|
||||
\textbf{If Goals Not Met}: Modify treatment plan
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Adjust medications (change dose, switch agents, add adjuvants)
|
||||
\item Add or modify interventional procedures
|
||||
\item Intensify physical therapy or psychological therapy
|
||||
\item Consider multidisciplinary pain rehabilitation program
|
||||
\item Reassess diagnosis (imaging, specialist consultation)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 5: SAFETY AND RISK MITIGATION =====
|
||||
\section*{5. Safety Planning and Risk Mitigation}
|
||||
|
||||
\subsection*{Opioid Safety (If Opioids Prescribed)}
|
||||
|
||||
\textbf{Opioid Treatment Agreement}: Patient signed agreement outlining:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Single prescriber and pharmacy
|
||||
\item No early refills
|
||||
\item Lost/stolen medications not replaced
|
||||
\item UDS and PDMP monitoring compliance
|
||||
\item Consequences of aberrant behavior
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Naloxone Prescription}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Naloxone (Narcan) nasal spray}: Prescribed to all patients on opioids
|
||||
\item \textbf{Education}: Family member trained on use for overdose reversal
|
||||
\item \textbf{Keep at Home}: Readily accessible
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Monitoring for Aberrant Behaviors}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Early refill requests
|
||||
\item Multiple lost prescriptions
|
||||
\item Obtaining opioids from other sources (PDMP)
|
||||
\item Positive UDS for non-prescribed substances
|
||||
\item Diversion suspected
|
||||
\item \textit{Action}: If concerning behaviors → reassess, taper, refer to addiction specialist
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Medication Safety}
|
||||
|
||||
\textbf{Drug Interactions}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Duloxetine + NSAIDs: Increased bleeding risk (monitor)
|
||||
\item Tizanidine + alcohol: Enhanced sedation (educate patient to avoid)
|
||||
\item Multiple CNS depressants: Additive sedation (avoid benzodiazepines with opioids)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Renal and Hepatic Function}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Baseline labs: BMP, LFTs
|
||||
\item Monitor every 6-12 months (NSAIDs nephrotoxic, duloxetine hepatotoxic rare)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{GI Protection}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Already on omeprazole (PPI) for GERD
|
||||
\item Adequate protection for NSAID use
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Emergency Procedures}
|
||||
|
||||
\textbf{Patient to call office or seek care if}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item New or worsening neurologic symptoms (weakness, numbness, bowel/bladder dysfunction - cauda equina)
|
||||
\item Severe uncontrolled pain despite medications
|
||||
\item Signs of medication overdose (excessive sedation, confusion, slow breathing)
|
||||
\item Allergic reaction to medications
|
||||
\item Severe side effects (GI bleeding, liver problems)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Call 911 for}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Suspected opioid overdose (unresponsive, slow/no breathing)
|
||||
\item Sudden onset severe back pain with leg weakness/paralysis
|
||||
\item Loss of bowel or bladder control (possible cauda equina syndrome)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 6: PATIENT EDUCATION =====
|
||||
\section*{6. Patient Education}
|
||||
|
||||
\subsection*{Understanding Chronic Pain}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Pain Neurobiology}: Central sensitization, pain pathways, why pain persists
|
||||
\item \textbf{Biopsychosocial Model}: Pain influenced by physical, psychological, and social factors
|
||||
\item \textbf{Realistic Expectations}: Complete pain elimination unlikely, but significant improvement possible
|
||||
\item \textbf{Active Participation}: Patient role in treatment (exercise, pacing, therapy homework) essential
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Medication Education}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item How each medication works
|
||||
\item Expected timeline for benefit (SNRIs take 4-6 weeks)
|
||||
\item Common side effects and management
|
||||
\item Importance of adherence (scheduled medications work better than PRN for chronic pain)
|
||||
\item Risks of opioids if prescribed (dependence, tolerance, side effects)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Self-Management Skills}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Activity pacing (alternate activity with rest, avoid overexertion)
|
||||
\item Proper body mechanics (lifting, bending)
|
||||
\item Home exercise program compliance
|
||||
\item Pain flare management (rest, ice/heat, medication adjustment)
|
||||
\item Stress reduction techniques
|
||||
\item Sleep hygiene practices
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Red Flags - When to Seek Immediate Care}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item New leg weakness or foot drop
|
||||
\item Loss of bowel or bladder control
|
||||
\item Numbness in saddle/groin area
|
||||
\item Severe pain not responsive to usual medications
|
||||
\item Fever with back pain (infection concern)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 7: MULTIDISCIPLINARY COORDINATION =====
|
||||
\section*{7. Care Coordination}
|
||||
|
||||
\textbf{Care Team}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Pain Specialist}: Medication management, interventional procedures
|
||||
\item \textbf{Primary Care Provider}: Overall health, comorbidity management, coordinate referrals
|
||||
\item \textbf{Physical Therapist}: Functional restoration, exercise program
|
||||
\item \textbf{Pain Psychologist}: CBT-CP, coping skills
|
||||
\item \textbf{Interventional Radiologist}: Perform injections (ESI, MBB, RFA)
|
||||
\item \textbf{Vocational Rehabilitation}: Return-to-work planning
|
||||
\item [Neurosurgery/Spine Surgeon: Consult if surgical candidacy changes]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Communication Plan}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item All providers share treatment plan
|
||||
\item Pain specialist sends notes to PCP after each visit
|
||||
\item PT and psychologist provide progress reports monthly
|
||||
\item Patient carries medication list and pain diary
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 8: DISCHARGE/TRANSITION PLANNING =====
|
||||
\section*{8. Long-Term Management and Transition}
|
||||
|
||||
\subsection*{If Goals Achieved}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Transition to maintenance phase
|
||||
\item Reduce visit frequency (every 3-6 months)
|
||||
\item Continue home exercise program indefinitely
|
||||
\item Taper medications if possible (especially opioids)
|
||||
\item Relapse prevention plan
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{If Refractory to Treatment}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Consider multidisciplinary pain rehabilitation program (intensive 3-4 week program)
|
||||
\item Re-evaluate for surgical candidacy
|
||||
\item Advanced interventions (SCS, intrathecal pump if appropriate)
|
||||
\item Palliative care consultation for severe refractory pain
|
||||
\item Vocational rehabilitation for permanent disability if unable to return to work
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 9: INFORMED CONSENT =====
|
||||
\section*{9. Informed Consent and Agreement}
|
||||
|
||||
\textbf{Risks and Benefits Discussed}:
|
||||
|
||||
\textbf{Benefits of Treatment Plan}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Pain reduction (goal 30-50\% reduction)
|
||||
\item Improved function and quality of life
|
||||
\item Better sleep
|
||||
\item Reduced depression and anxiety
|
||||
\item Potential return to work
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Risks}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Medication side effects (GI upset, sedation, others)
|
||||
\item Opioid risks if prescribed (dependence, tolerance, overdose)
|
||||
\item Injection risks (infection, bleeding, nerve injury - rare)
|
||||
\item Treatment may not be fully effective
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Patient Responsibilities}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Take medications as prescribed
|
||||
\item Attend all therapy appointments (PT, psychology)
|
||||
\item Complete home exercise program
|
||||
\item Keep pain diary
|
||||
\item Communicate openly about pain and side effects
|
||||
\item If on opioids: Comply with opioid agreement, UDS, PDMP
|
||||
\end{itemize}
|
||||
|
||||
Patient demonstrates understanding, questions answered, agrees to proceed with comprehensive pain management plan.
|
||||
|
||||
% ===== SECTION 10: SIGNATURES =====
|
||||
\vspace{2em}
|
||||
|
||||
\section*{10. Provider Signature and Attestation}
|
||||
|
||||
This comprehensive pain management plan has been reviewed with the patient. The patient understands the multimodal approach, realistic expectations, risks and benefits of treatments, and their responsibilities in pain management. If opioid therapy is included, an opioid treatment agreement has been signed separately.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Provider Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Provider Name/Credentials: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\[2em]
|
||||
\end{tabular}
|
||||
|
||||
\subsection*{Patient Acknowledgment}
|
||||
|
||||
I have reviewed this pain management plan with my provider. I understand the treatments recommended, realistic expectations for pain relief, and my role in managing my pain. I agree to participate actively in this plan.
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\begin{tabular}{ll}
|
||||
Patient Signature: & \rule{7cm}{0.5pt} \\[1em]
|
||||
Date: & \rule{4cm}{0.5pt} \\
|
||||
\end{tabular}
|
||||
|
||||
\vspace{2em}
|
||||
\begin{center}
|
||||
\rule{\textwidth}{1pt}\\
|
||||
\textbf{End of Pain Management Plan}\\
|
||||
This document contains confidential patient information protected by HIPAA.
|
||||
\end{center}
|
||||
|
||||
\end{document}
|
||||
|
||||
% ========== NOTES FOR USERS ==========
|
||||
%
|
||||
% KEY PRINCIPLES:
|
||||
% - Multimodal opioid-sparing approach
|
||||
% - CDC opioid prescribing guidelines compliance
|
||||
% - Functional improvement as primary goal (not just pain scores)
|
||||
% - Biopsychosocial model of pain
|
||||
% - Patient education and self-management emphasis
|
||||
%
|
||||
% CUSTOMIZATION:
|
||||
% - Adjust medications based on pain type (nociceptive vs. neuropathic)
|
||||
% - Select interventions appropriate for pain generator
|
||||
% - Modify based on patient comorbidities and contraindications
|
||||
% - Adapt psychological interventions to patient preference
|
||||
%
|
||||
% OPIOID CONSIDERATIONS:
|
||||
% - Use only after non-opioid therapies inadequate
|
||||
% - Lowest effective dose, short-acting preferred initially
|
||||
% - Close monitoring, UDS, PDMP
|
||||
% - Naloxone co-prescription
|
||||
% - Reassess regularly, taper if not meeting goals
|
||||
%
|
||||
% COMPILATION:
|
||||
% pdflatex pain_management_plan.tex
|
||||
|
||||
753
skills/treatment-plans/assets/perioperative_care_plan.tex
Normal file
753
skills/treatment-plans/assets/perioperative_care_plan.tex
Normal file
@@ -0,0 +1,753 @@
|
||||
% Perioperative Care Plan Template
|
||||
% For surgical and procedural patient management
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[11pt,letterpaper]{article}
|
||||
|
||||
% Packages
|
||||
\usepackage[top=1in,bottom=1in,left=1in,right=1in]{geometry}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{array}
|
||||
\usepackage{longtable}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{lastpage}
|
||||
\usepackage{tabularx}
|
||||
\usepackage[most]{tcolorbox}
|
||||
|
||||
% Header and footer
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\lhead{Perioperative Care Plan}
|
||||
\rhead{Page \thepage\ of \pageref{LastPage}}
|
||||
\lfoot{Date Created: \today}
|
||||
\rfoot{Confidential Patient Information}
|
||||
|
||||
% Title formatting
|
||||
\usepackage{titlesec}
|
||||
\titleformat{\section}{\large\bfseries}{\thesection}{1em}{}
|
||||
\titleformat{\subsection}{\normalsize\bfseries}{\thesubsection}{1em}{}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% Title
|
||||
\begin{center}
|
||||
{\Large\bfseries PERIOPERATIVE CARE PLAN}\\[0.5em]
|
||||
{\large Surgical \& Procedural Patient Management}\\[0.5em]
|
||||
\rule{\textwidth}{1pt}
|
||||
\end{center}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== TREATMENT PLAN HIGHLIGHTS (Foundation Medicine Model) =====
|
||||
\begin{tcolorbox}[colback=red!5!white,colframe=red!75!black,title=\textbf{TREATMENT PLAN HIGHLIGHTS},fonttitle=\bfseries\large]
|
||||
|
||||
\textbf{Procedure:} [Planned surgery/procedure - e.g., Laparoscopic cholecystectomy for symptomatic cholelithiasis]
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Primary Perioperative Goals:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item [Goal 1 - e.g., Safe completion of procedure with minimal complications]
|
||||
\item [Goal 2 - e.g., Discharge within 24 hours (outpatient procedure)]
|
||||
\item [Goal 3 - e.g., Return to normal activities within 2 weeks]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Key Perioperative Elements:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Preoperative:} [Optimization - e.g., ASA class II, medical clearance obtained, NPO after midnight]
|
||||
\item \textit{Intraoperative:} [Approach - e.g., General anesthesia, standard laparoscopic technique]
|
||||
\item \textit{Postoperative:} [Recovery - e.g., Early mobilization, multimodal analgesia, same-day discharge]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Timeline:} [Schedule - e.g., Surgery date [XX/XX], follow-up at 2 weeks, full recovery 4-6 weeks]
|
||||
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== SECTION 1: PATIENT AND PROCEDURE INFORMATION =====
|
||||
\section*{1. Patient and Procedure Information}
|
||||
|
||||
\textbf{HIPAA Notice}: De-identify all protected health information before sharing.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Patient ID} & [De-identified code, e.g., SURG-001] \\ \hline
|
||||
\textbf{Age Range} & [e.g., 65-70 years] \\ \hline
|
||||
\textbf{Sex} & [Male/Female/Other] \\ \hline
|
||||
\textbf{Date of Plan} & [Month/Year only] \\ \hline
|
||||
\textbf{Surgeon} & [Name, MD, Specialty] \\ \hline
|
||||
\textbf{Anesthesiologist} & [Name, MD or assigned team] \\ \hline
|
||||
\textbf{Planned Procedure} & [e.g., Elective total knee arthroplasty, right] \\ \hline
|
||||
\textbf{CPT Code} & [e.g., 27447] \\ \hline
|
||||
\textbf{Scheduled Date} & [Month/Year or "Within 2-4 weeks"] \\ \hline
|
||||
\textbf{Facility} & [Hospital/Surgery center name] \\ \hline
|
||||
\textbf{Expected LOS} & [e.g., 2-3 days] \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\subsection*{Surgical Indication}
|
||||
|
||||
\textbf{Primary Diagnosis}: [e.g., Severe osteoarthritis, right knee] (ICD-10: [M17.11])
|
||||
|
||||
\textbf{Indication for Surgery}:
|
||||
[e.g., Patient has severe right knee pain (8/10) limiting mobility and function despite conservative management including physical therapy, weight loss, and analgesics. Radiographs demonstrate bone-on-bone contact, osteophytes, and joint space narrowing. Failed conservative treatment for 12+ months. Patient desires surgical intervention to improve quality of life and function.]
|
||||
|
||||
\textbf{Previous Treatments}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Physical therapy (6 months, minimal benefit)
|
||||
\item Weight loss (15 lbs, ongoing)
|
||||
\item NSAIDs, acetaminophen (limited efficacy)
|
||||
\item Intra-articular corticosteroid injections (3 injections, temporary relief only)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Medical History and Comorbidities}
|
||||
|
||||
\textbf{Active Medical Conditions}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Hypertension}: Well-controlled on lisinopril 20mg daily
|
||||
\item \textbf{Type 2 Diabetes}: HbA1c 6.8\%, well-controlled on metformin
|
||||
\item \textbf{Hyperlipidemia}: On atorvastatin 40mg
|
||||
\item \textbf{Obesity}: BMI 32 (down from 35 with weight loss efforts)
|
||||
\item [List additional conditions]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Current Medications}:
|
||||
\begin{longtable}{|p{3cm}|p{2cm}|p{2cm}|p{6cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Perioperative Plan} \\ \hline
|
||||
Lisinopril & 20mg & Daily & Hold day of surgery, resume POD 1 if BP stable \\ \hline
|
||||
Metformin & 1000mg & BID & Hold 24 hours before surgery, resume when eating \\ \hline
|
||||
Atorvastatin & 40mg & QHS & Continue through surgery \\ \hline
|
||||
Aspirin & 81mg & Daily & Discuss with surgeon - likely continue \\ \hline
|
||||
Ibuprofen & 600mg & PRN & Discontinue 5-7 days before surgery \\ \hline
|
||||
[Add medications] & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Allergies}: [NKDA or list medication allergies and reactions]
|
||||
|
||||
\subsection*{Preoperative Risk Assessment}
|
||||
|
||||
\textbf{ASA Physical Status Classification}: [e.g., ASA Class II - Mild systemic disease (HTN, DM)]
|
||||
|
||||
\textbf{Cardiac Risk} (Revised Cardiac Risk Index - RCRI):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item High-risk surgery: ☐ Yes ☑ No (orthopedic is intermediate-risk)
|
||||
\item Ischemic heart disease: ☐ Yes ☑ No
|
||||
\item Heart failure: ☐ Yes ☑ No
|
||||
\item Cerebrovascular disease: ☐ Yes ☑ No
|
||||
\item Diabetes on insulin: ☐ Yes ☑ No
|
||||
\item Creatinine $>$2 mg/dL: ☐ Yes ☑ No
|
||||
\item \textbf{RCRI Score}: 0 (Low risk $<$1\% cardiac event)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Pulmonary Risk}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item No active pulmonary disease
|
||||
\item No smoking history
|
||||
\item Room air oxygen saturation 98\%
|
||||
\item Low risk for postoperative pulmonary complications
|
||||
\end{itemize}
|
||||
|
||||
\textbf{VTE Risk} (Caprini Score):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Age 65-70: 2 points
|
||||
\item Major surgery ($>$45 min): 2 points
|
||||
\item BMI $>$30: 1 point
|
||||
\item \textbf{Total Score}: 5 (Moderate-high risk)
|
||||
\item \textbf{Prophylaxis Plan}: Pharmacologic (enoxaparin) + mechanical (SCDs)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Bleeding Risk}: Low (no anticoagulation, normal coagulation studies)
|
||||
|
||||
% ===== SECTION 2: PREOPERATIVE OPTIMIZATION =====
|
||||
\section*{2. Preoperative Optimization and Preparation}
|
||||
|
||||
\subsection*{2.1 Medical Optimization}
|
||||
|
||||
\textbf{Diabetes Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Goal}: HbA1c $<$7-8\% for elective surgery (current 6.8\% - optimized)
|
||||
\item \textbf{Preop Day}: Hold metformin 24 hours before surgery
|
||||
\item \textbf{Morning of Surgery}: NPO, no oral hypoglycemics
|
||||
\item \textbf{Glucose Monitoring}: Check fasting glucose morning of surgery, target 100-180 mg/dL
|
||||
\item \textbf{Perioperative Protocol}: Insulin sliding scale if glucose $>$180 mg/dL
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Hypertension Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Goal}: BP $<$140/90 preoperatively (current 128/76 - controlled)
|
||||
\item \textbf{Medication Plan}: Hold lisinopril morning of surgery (avoid intraop hypotension)
|
||||
\item \textbf{Beta-blockers}: [If on beta-blocker, continue through surgery]
|
||||
\item \textbf{Postop}: Resume home BP medications when tolerating oral intake
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Cardiac Clearance}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Assessment}: Low cardiac risk (RCRI 0), intermediate-risk surgery
|
||||
\item \textbf{Functional Capacity}: $>$4 METs (can climb 1 flight of stairs)
|
||||
\item \textbf{EKG}: Normal sinus rhythm, no acute changes
|
||||
\item \textbf{Additional Testing}: Not needed (low risk, good functional capacity)
|
||||
\item \textbf{Cardiology Consultation}: Not indicated
|
||||
\item \textbf{Cleared for Surgery}: Yes
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Pulmonary Optimization}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Smoking Cessation}: N/A (non-smoker)
|
||||
\item \textbf{Incentive Spirometry}: Education provided, will use postoperatively
|
||||
\item \textbf{Pulmonary Function Tests}: Not indicated (no pulmonary disease)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Nutritional Status}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Albumin}: [e.g., 4.0 g/dL - normal]
|
||||
\item \textbf{BMI}: 32 (obese, but weight loss of 15 lbs achieved)
|
||||
\item \textbf{Nutritional Optimization}: Adequate, no protein supplementation needed
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Anemia Screening and Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Preop Hemoglobin}: [e.g., 13.2 g/dL - normal]
|
||||
\item \textbf{Iron Studies}: [If low Hgb - check iron, ferritin, TIBC]
|
||||
\item \textbf{Optimization}: No anemia present, no intervention needed
|
||||
\item \textbf{Transfusion Threshold}: Hgb $<$7-8 g/dL postoperatively (restrictive strategy)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.2 Medication Management}
|
||||
|
||||
\textbf{Medications to Continue}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Statin (atorvastatin)
|
||||
\item Aspirin 81mg (after surgeon confirmation - typically continued for orthopedic)
|
||||
\item [Other chronic medications per anesthesia recommendations]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Medications to Hold}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{NSAIDs}: Discontinue 5-7 days before surgery (ibuprofen)
|
||||
\item \textbf{ACE Inhibitors}: Hold day of surgery (lisinopril)
|
||||
\item \textbf{Metformin}: Hold 24 hours before, resume when eating normally
|
||||
\item \textbf{[Other medications]}: [Specific instructions]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Anticoagulation Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Not applicable (patient not on anticoagulation)
|
||||
\item [If on warfarin: bridge with LMWH, target INR $<$1.5]
|
||||
\item [If on DOAC: hold 24-48 hours based on renal function]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.3 Preoperative Testing and Clearance}
|
||||
|
||||
\textbf{Laboratory Tests}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item CBC: [Results - Hgb, platelets]
|
||||
\item BMP: [Results - creatinine, glucose, electrolytes]
|
||||
\item HbA1c: 6.8\% (within 3 months)
|
||||
\item Coagulation studies (PT/INR, PTT): [If indicated]
|
||||
\item Type and screen: [Completed, blood available if needed]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Imaging}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Chest X-ray: [If indicated - age $>$50 with cardiac/pulmonary disease]
|
||||
\item Preop knee X-rays: Confirm diagnosis, surgical planning
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Medical Clearance}: ☑ Cleared for surgery by PCP [Date]
|
||||
|
||||
\subsection*{2.4 Enhanced Recovery After Surgery (ERAS) Protocol}
|
||||
|
||||
\textbf{Preoperative ERAS Elements}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Patient Education}: Provided ERAS booklet, reviewed expectations
|
||||
\item \textbf{Nutritional Optimization}: Carbohydrate loading (clear carb drink 2 hours before surgery)
|
||||
\item \textbf{Fasting Guidelines}: NPO solid food 6 hours, clear liquids until 2 hours before
|
||||
\item \textbf{Preoperative Bathing}: Chlorhexidine shower night before and morning of surgery
|
||||
\item \textbf{No Premedication}: Avoid long-acting sedatives (faster recovery)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 3: PERIOPERATIVE GOALS =====
|
||||
\section*{3. Perioperative Goals}
|
||||
|
||||
\subsection*{3.1 Immediate Perioperative Goals (Day 0-1)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Pain Control}: Achieve pain $\leq$4/10 at rest, $\leq$6/10 with movement using multimodal analgesia by POD 0.
|
||||
|
||||
\item \textbf{Early Mobilization}: Out of bed to chair within 4-6 hours post-surgery (day of surgery if morning case).
|
||||
|
||||
\item \textbf{Nausea/Vomiting Prevention}: No or minimal PONV with multimodal antiemetic prophylaxis.
|
||||
|
||||
\item \textbf{Glucose Control}: Maintain blood glucose 100-180 mg/dL perioperatively.
|
||||
|
||||
\item \textbf{Hemodynamic Stability}: Maintain BP within 20\% of baseline, avoid hypo/hypertension.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.2 Early Postoperative Goals (POD 1-3)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Mobilization}: Ambulate with physical therapy 50+ feet with walker by POD 1, progress to 150 feet by POD 2.
|
||||
|
||||
\item \textbf{ROM}: Achieve knee flexion $>$70 degrees and full extension by POD 2.
|
||||
|
||||
\item \textbf{Pain Management}: Transition to oral multimodal analgesia, pain $\leq$5/10, minimize opioid use.
|
||||
|
||||
\item \textbf{Diet Advancement}: Resume regular diet POD 1, adequate oral intake.
|
||||
|
||||
\item \textbf{Bowel Function}: Return of bowel sounds, pass flatus by POD 2.
|
||||
|
||||
\item \textbf{Urinary Function}: Foley catheter removed POD 0-1, spontaneous void within 6-8 hours.
|
||||
|
||||
\item \textbf{Prevent Complications}: No surgical site infection, DVT, PE, or other major complications.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.3 Discharge Goals (POD 2-3)}
|
||||
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Functional Mobility}: Independent transfers, ambulate 150+ feet with assistive device, negotiate stairs if needed for home.
|
||||
|
||||
\item \textbf{Pain Control}: Adequate pain control on oral medications, pain $<$5/10.
|
||||
|
||||
\item \textbf{Safety}: Patient/family demonstrate understanding of precautions, medications, wound care.
|
||||
|
||||
\item \textbf{Discharge Readiness}: Stable vital signs, no complications, safe for discharge home (with home health if needed).
|
||||
\end{enumerate}
|
||||
|
||||
% ===== SECTION 4: INTRAOPERATIVE MANAGEMENT =====
|
||||
\section*{4. Intraoperative Management Plan}
|
||||
|
||||
\subsection*{Anesthesia Plan}
|
||||
|
||||
\textbf{Anesthesia Type}: [e.g., Spinal anesthesia + sedation] (surgeon/anesthesia preference)
|
||||
|
||||
\textbf{Alternatives Discussed}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item General anesthesia
|
||||
\item Regional anesthesia (spinal/epidural)
|
||||
\item Peripheral nerve block (femoral, adductor canal block)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Multimodal Analgesia - Intraoperative}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Regional anesthesia (spinal/block) as primary analgesic
|
||||
\item IV acetaminophen 1g intraoperatively
|
||||
\item Ketorolac 15-30mg IV (if no contraindication)
|
||||
\item Local anesthetic infiltration at surgical site (surgeon)
|
||||
\item Minimize intraop opioids (opioid-sparing approach)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{PONV Prophylaxis}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Ondansetron 4mg IV
|
||||
\item Dexamethasone 4-8mg IV
|
||||
\item Scopolamine patch (if high PONV risk)
|
||||
\item Avoid volatile anesthetics if possible (TIVA preferred)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Surgical Approach}
|
||||
|
||||
\textbf{Procedure}: Total knee arthroplasty, cemented components
|
||||
|
||||
\textbf{Antibiotic Prophylaxis}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Cefazolin 2g IV within 60 minutes of incision (3g if weight $>$120 kg)
|
||||
\item Redose if surgery $>$4 hours or blood loss $>$1500 mL
|
||||
\item Discontinue within 24 hours post-surgery
|
||||
\end{itemize}
|
||||
|
||||
\textbf{VTE Prophylaxis - Intraoperative}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Sequential compression devices (SCDs) applied before induction
|
||||
\item Continue SCDs throughout hospitalization and at rest at home
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Surgical Site Infection Prevention}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Chlorhexidine-alcohol skin prep
|
||||
\item Maintain normothermia (goal temp $>$36°C)
|
||||
\item Glucose control (intraop glucose $<$180 mg/dL)
|
||||
\item Surgical time minimize (planned $<$2 hours)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Blood Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Tranexamic acid 1-2g IV (reduce blood loss)
|
||||
\item Cell saver if appropriate
|
||||
\item Restrictive transfusion strategy (Hgb $<$7-8 g/dL)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 5: POSTOPERATIVE MANAGEMENT =====
|
||||
\section*{5. Postoperative Management Plan}
|
||||
|
||||
\subsection*{5.1 Pain Management (Multimodal Analgesia)}
|
||||
|
||||
\textbf{ERAS Pain Protocol} (opioid-minimizing):
|
||||
|
||||
\begin{longtable}{|p{3.5cm}|p{2.5cm}|p{7cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose/Frequency} & \textbf{Instructions} \\ \hline
|
||||
\textbf{Acetaminophen} & 1000mg Q6H & Scheduled (not PRN), around-the-clock for 48 hours \\ \hline
|
||||
\textbf{Celecoxib} or \textbf{Meloxicam} & 200mg BID or 15mg daily & NSAID (if no contraindication), scheduled x 7-14 days \\ \hline
|
||||
\textbf{Gabapentin} & 300mg TID & Neuropathic pain adjuvant, start preop or POD 0 \\ \hline
|
||||
\textbf{Ice therapy} & Q2H while awake & Local cooling, reduces swelling and pain \\ \hline
|
||||
\textbf{Oxycodone} & 5mg Q4H PRN & Breakthrough pain only, goal minimize use \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Pain Assessment}: Numeric rating scale (0-10) every 4 hours, before and after ambulation
|
||||
|
||||
\textbf{Pain Goals}: $\leq$4/10 at rest, $\leq$6/10 with PT/activity
|
||||
|
||||
\subsection*{5.2 Early Mobilization and Physical Therapy}
|
||||
|
||||
\textbf{ERAS Mobility Protocol}:
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{POD 0 (Day of Surgery)}: Out of bed to chair 4-6 hours post-op, stand at bedside
|
||||
\item \textbf{POD 1}:
|
||||
\begin{itemize}
|
||||
\item PT evaluation and gait training
|
||||
\item Ambulate 50+ feet with walker x2
|
||||
\item Begin ROM exercises (CPM machine or therapist-assisted)
|
||||
\item Stair practice if needed for home
|
||||
\end{itemize}
|
||||
\item \textbf{POD 2}:
|
||||
\begin{itemize}
|
||||
\item Ambulate 150+ feet with walker x2-3
|
||||
\item ROM: Goal flexion $>$90 degrees
|
||||
\item Independent bed mobility and transfers
|
||||
\item Stairs if required
|
||||
\end{itemize}
|
||||
\item \textbf{Discharge Criteria}: Ambulate 150 feet, transfers independently, stairs if applicable
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Fall Precautions}: High risk post-surgery - bed alarm, non-slip socks, walker, call for assist
|
||||
|
||||
\subsection*{5.3 Nausea and Vomiting Management}
|
||||
|
||||
\textbf{Multimodal Antiemetic Protocol}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Ondansetron 4mg IV/PO Q6H PRN
|
||||
\item Metoclopramide 10mg IV Q6H PRN (if ondansetron insufficient)
|
||||
\item Scopolamine patch (continue 72 hours if applied)
|
||||
\item Non-pharmacologic: Ginger ale, acupressure bands, avoid rapid position changes
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{5.4 Nutrition and Diet Advancement}
|
||||
|
||||
\textbf{ERAS Nutrition}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Resume diet as tolerated POD 0-1 (no prolonged NPO)
|
||||
\item Protein-rich diet (wound healing)
|
||||
\item Adequate hydration
|
||||
\item No routine NG tube
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{5.5 VTE Prophylaxis}
|
||||
|
||||
\textbf{Pharmacologic} (High-risk orthopedic surgery):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Enoxaparin 40mg SC daily} starting POD 1, continue 10-14 days
|
||||
\item \textit{Alternative}: Apixaban 2.5mg BID x 12 days (extended prophylaxis)
|
||||
\item Hold first dose if neuraxial anesthesia (spinal/epidural) until catheter removal + 12 hours
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Mechanical}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item SCDs while in bed throughout hospitalization
|
||||
\item Early mobilization (most important)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Duration}: Minimum 10-14 days, consider up to 35 days for high-risk patients
|
||||
|
||||
\subsection*{5.6 Urinary Catheter Management}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Foley Catheter}: Typically placed intraoperatively
|
||||
\item \textbf{Removal}: POD 0 or POD 1 morning (early removal to prevent CAUTI)
|
||||
\item \textbf{Voiding Trial}: Must void within 6-8 hours of catheter removal
|
||||
\item \textbf{Retention Protocol}: If unable to void or bladder scan $>$400 mL, straight cath or replace Foley temporarily
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{5.7 Wound Care and Drain Management}
|
||||
|
||||
\textbf{Surgical Drain}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Hemovac or JP drain typically placed
|
||||
\item Monitor output, remove when $<$30 mL/8 hours (usually POD 1-2)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Dressing}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Keep clean and dry
|
||||
\item First dressing change POD 2 or per surgeon
|
||||
\item Assess for signs of infection daily
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{5.8 Glycemic Control}
|
||||
|
||||
\textbf{Postoperative Glucose Management}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Target glucose 100-180 mg/dL
|
||||
\item Check glucose Q6H while NPO or on IV fluids
|
||||
\item Insulin sliding scale (SSI) if glucose $>$180 mg/dL
|
||||
\item Resume metformin when tolerating regular diet and creatinine stable
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{5.9 Complication Surveillance}
|
||||
|
||||
\textbf{Monitor for}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Surgical site infection}: Fever, wound erythema, purulent drainage, increased pain
|
||||
\item \textbf{DVT/PE}: Unilateral leg swelling, chest pain, dyspnea, hypoxia
|
||||
\item \textbf{Acute kidney injury}: Decreased UOP, rising creatinine
|
||||
\item \textbf{Cardiovascular events}: Chest pain, EKG changes, troponin elevation
|
||||
\item \textbf{Delirium}: Especially in elderly, multimodal prevention
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 6: DISCHARGE PLANNING =====
|
||||
\section*{6. Discharge Planning and Criteria}
|
||||
|
||||
\subsection*{Discharge Criteria (Typically POD 2-3)}
|
||||
|
||||
Patient ready for discharge when ALL met:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ☐ Adequate pain control on oral medications (pain $<$5/10)
|
||||
\item ☐ Functional mobility: Ambulate 150+ feet, transfers, stairs if needed
|
||||
\item ☐ Tolerating regular diet, adequate oral intake
|
||||
\item ☐ Voiding spontaneously without catheter
|
||||
\item ☐ Stable vital signs, no fever $>$38.5°C x 24 hours
|
||||
\item ☐ No complications requiring continued hospitalization
|
||||
\item ☐ Adequate home support and DME arranged
|
||||
\item ☐ Patient/family education completed, demonstrate understanding
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Discharge Medications}
|
||||
|
||||
\begin{longtable}{|p{3cm}|p{2cm}|p{2cm}|p{6cm}|}
|
||||
\hline
|
||||
\textbf{Medication} & \textbf{Dose} & \textbf{Frequency} & \textbf{Duration/Instructions} \\ \hline
|
||||
Oxycodone & 5mg & Q4-6H PRN & Pain, 20 tablets (minimize use) \\ \hline
|
||||
Acetaminophen & 1000mg & Q6H & Scheduled x 2 weeks \\ \hline
|
||||
Meloxicam & 15mg & Daily & x 2 weeks (NSAID) \\ \hline
|
||||
Enoxaparin & 40mg SC & Daily & x 10-14 days (VTE prophylaxis) \\ \hline
|
||||
Colace & 100mg & BID & Constipation prevention while on opioids \\ \hline
|
||||
[Resume home meds] & & & Resume lisinopril, metformin, atorvastatin \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Durable Medical Equipment (DME)}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Walker (front-wheeled, standard adult)
|
||||
\item Raised toilet seat with arms
|
||||
\item Shower chair or bath bench
|
||||
\item Reacher (32-inch)
|
||||
\item Ice machine or ice packs (for knee)
|
||||
\item Long-handled shoe horn (hip precautions if applicable)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Home Services}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Home Health Physical Therapy}: 2-3x/week x 2-3 weeks, then transition to outpatient PT
|
||||
\item \textbf{Home Health Nursing}: PRN for wound check, drain removal if not removed before discharge, medication teaching (enoxaparin injections)
|
||||
\item [If high needs: Home health aide for ADL assistance]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Patient Education Completed}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ✓ Wound care and dressing changes
|
||||
\item ✓ Signs of infection (fever, redness, drainage, increased pain)
|
||||
\item ✓ Pain medication use and weaning plan
|
||||
\item ✓ Enoxaparin self-injection technique (or family member trained)
|
||||
\item ✓ DVT/PE warning signs (leg swelling, chest pain, shortness of breath)
|
||||
\item ✓ Activity restrictions and precautions
|
||||
\item ✓ Home exercise program
|
||||
\item ✓ Use of DME (walker, raised toilet seat, etc.)
|
||||
\item ✓ When to call surgeon (fever $>$101.5°F, severe pain, wound concerns)
|
||||
\item ✓ Follow-up appointments scheduled
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Activity Restrictions}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Use walker for ambulation x 2-4 weeks (per PT recommendation)
|
||||
\item No driving until off opioid pain medications and cleared by surgeon (typically 2-4 weeks)
|
||||
\item No prolonged sitting $>$30-45 min without getting up and moving
|
||||
\item Avoid kneeling on operative knee
|
||||
\item Gradual return to activities as tolerated
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Follow-Up Appointments}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|l|X|}
|
||||
\hline
|
||||
\textbf{Provider} & \textbf{Timing} & \textbf{Purpose} \\ \hline
|
||||
Surgeon & 10-14 days & Wound check, staple/suture removal, assess progress \\ \hline
|
||||
Surgeon & 6 weeks & X-ray, functional assessment, advance activities \\ \hline
|
||||
Surgeon & 3 months, 6 months, 1 year & Long-term follow-up, outcomes \\ \hline
|
||||
PCP & 1-2 weeks & Resume chronic disease management, BP/DM check \\ \hline
|
||||
PT (outpatient) & After home health complete & Continue strengthening, ROM, return to function \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
% ===== SECTION 7: EMERGENCY PROCEDURES =====
|
||||
\section*{7. Postoperative Emergency Procedures}
|
||||
|
||||
\textbf{Call surgeon immediately or go to ED if}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Fever $>$101.5°F (38.6°C)
|
||||
\item Severe uncontrolled pain ($>$7/10 despite medications)
|
||||
\item Wound: Excessive drainage, purulent discharge, wound dehiscence, foul odor
|
||||
\item Increased redness, warmth, or swelling at surgical site
|
||||
\item DVT symptoms: Unilateral leg swelling, pain, warmth, redness
|
||||
\item PE symptoms: Sudden chest pain, shortness of breath, rapid heart rate
|
||||
\item Numbness, tingling, or weakness in leg (nerve injury concern)
|
||||
\item Inability to urinate
|
||||
\item Excessive bleeding from surgical site
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Call 911 for}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Chest pain or pressure
|
||||
\item Severe shortness of breath
|
||||
\item Loss of consciousness
|
||||
\item Signs of stroke (facial droop, arm weakness, speech difficulty)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Surgeon Contact Information}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Office: [Phone number]
|
||||
\item After-hours/Emergency: [On-call service number]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 8: REHABILITATION AND RECOVERY =====
|
||||
\section*{8. Rehabilitation Plan and Expected Recovery}
|
||||
|
||||
\subsection*{Recovery Timeline}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Timeframe} & \textbf{Expected Progress} \\ \hline
|
||||
Week 1-2 & Wound healing, pain decreasing, ambulation with walker improving, ROM exercises \\ \hline
|
||||
Week 3-6 & Transition from walker to cane, ROM improving (goal flexion $>$100°), less pain \\ \hline
|
||||
Week 6-12 & Progress to independent ambulation (no assistive device), ROM 110-120° flexion, strengthening phase \\ \hline
|
||||
3-6 months & Return to most activities, continued strengthening, ROM optimization, minimal pain \\ \hline
|
||||
6-12 months & Full recovery, return to all desired activities, final ROM achieved \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Physical Therapy Goals}
|
||||
|
||||
\textbf{Short-term} (0-6 weeks):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ROM: Flexion $>$90° by week 2, $>$110° by week 6, full extension
|
||||
\item Strength: Quadriceps, hamstrings, hip abductors
|
||||
\item Ambulation: Progress from walker to cane to independent
|
||||
\item Stairs: Negotiate safely
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Long-term} (6 weeks - 3 months):
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item ROM: Maximum flexion (goal 120-125°)
|
||||
\item Strength: Near-normal lower extremity strength
|
||||
\item Function: Return to ADLs, hobbies, light sports
|
||||
\item Gait: Normal gait pattern without assistive device
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Home Exercise Program}
|
||||
|
||||
\textit{Provided by PT, to be performed 2-3x daily}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Ankle pumps
|
||||
\item Quad sets
|
||||
\item Straight leg raises
|
||||
\item Hamstring curls
|
||||
\item Hip abduction
|
||||
\item Knee flexion/extension ROM exercises
|
||||
\item Heel slides
|
||||
\item Stationary bike (when cleared)
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 9: INFORMED CONSENT =====
|
||||
\section*{9. Informed Consent Documentation}
|
||||
|
||||
\textbf{Risks and Benefits Discussed}:
|
||||
|
||||
\textbf{Benefits}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Pain relief (90\% significant improvement)
|
||||
\item Improved function and mobility
|
||||
\item Enhanced quality of life
|
||||
\item Return to desired activities
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Risks}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Infection ($<$2\%)
|
||||
\item DVT/PE (2-3\% despite prophylaxis)
|
||||
\item Bleeding, hematoma
|
||||
\item Nerve or blood vessel injury (rare)
|
||||
\item Stiffness, limited ROM
|
||||
\item Implant loosening, wear (long-term)
|
||||
\item Need for revision surgery (10-15\% lifetime risk)
|
||||
\item Anesthesia risks
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Alternatives Discussed}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Continued conservative management (PT, medications, injections)
|
||||
\item Partial knee replacement (if eligible)
|
||||
\item No treatment
|
||||
\end{itemize}
|
||||
|
||||
Patient demonstrates understanding, all questions answered, consents to proceed with surgery.
|
||||
|
||||
% ===== SECTION 10: SIGNATURES =====
|
||||
\vspace{2em}
|
||||
|
||||
\section*{10. Provider Signatures}
|
||||
|
||||
\textbf{Surgeon}:\\[0.5em]
|
||||
Signature: \rule{6cm}{0.5pt} \quad Date: \rule{3cm}{0.5pt}\\
|
||||
Name/Credentials: \rule{6cm}{0.5pt}\\[1em]
|
||||
|
||||
\textbf{Anesthesiologist}:\\[0.5em]
|
||||
Signature: \rule{6cm}{0.5pt} \quad Date: \rule{3cm}{0.5pt}\\
|
||||
Name/Credentials: \rule{6cm}{0.5pt}\\[1em]
|
||||
|
||||
\textbf{Patient Consent}:\\[0.5em]
|
||||
I have reviewed this perioperative care plan. I understand the procedure, risks, benefits, and alternatives. My questions have been answered. I consent to the planned surgery.\\[0.5em]
|
||||
Signature: \rule{6cm}{0.5pt} \quad Date: \rule{3cm}{0.5pt}\\
|
||||
|
||||
\vspace{2em}
|
||||
\begin{center}
|
||||
\rule{\textwidth}{1pt}\\
|
||||
\textbf{End of Perioperative Care Plan}\\
|
||||
This document contains confidential patient information protected by HIPAA.
|
||||
\end{center}
|
||||
|
||||
\end{document}
|
||||
|
||||
% ========== NOTES FOR USERS ==========
|
||||
%
|
||||
% This template emphasizes Enhanced Recovery After Surgery (ERAS) principles
|
||||
% Key ERAS elements: preop carbohydrate loading, minimal fasting, multimodal analgesia,
|
||||
% early mobilization, early feeding, minimizing tubes/drains, VTE prophylaxis
|
||||
%
|
||||
% CUSTOMIZATION:
|
||||
% - Adjust for specific surgical procedure
|
||||
% - Modify based on patient comorbidities
|
||||
% - Update medication protocols per institutional guidelines
|
||||
% - Adapt ERAS elements based on evidence and surgeon preference
|
||||
%
|
||||
% COMPILATION:
|
||||
% pdflatex perioperative_care_plan.tex
|
||||
|
||||
471
skills/treatment-plans/assets/quality_checklist.md
Normal file
471
skills/treatment-plans/assets/quality_checklist.md
Normal file
@@ -0,0 +1,471 @@
|
||||
# Treatment Plan Quality Assurance Checklist
|
||||
|
||||
## Overview
|
||||
|
||||
Use this checklist to ensure treatment plans meet professional standards for completeness, quality, safety, and regulatory compliance. Review each section before finalizing the plan.
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Completeness - Required Components
|
||||
|
||||
### ☐ Patient Information
|
||||
- [ ] Patient identifier (de-identified if sharing)
|
||||
- [ ] Age range (not exact date of birth)
|
||||
- [ ] Sex and relevant demographics
|
||||
- [ ] Date of plan creation
|
||||
- [ ] Provider name and credentials
|
||||
- [ ] Facility/practice name
|
||||
- [ ] HIPAA de-identification notice included
|
||||
|
||||
### ☐ Diagnosis and Assessment
|
||||
- [ ] Primary diagnosis clearly stated
|
||||
- [ ] ICD-10 code(s) included
|
||||
- [ ] Secondary diagnoses and comorbidities listed
|
||||
- [ ] Disease severity/staging documented
|
||||
- [ ] Baseline functional status assessed
|
||||
- [ ] Risk stratification performed (if applicable)
|
||||
|
||||
### ☐ Treatment Goals
|
||||
- [ ] Short-term goals present (1-3 months)
|
||||
- [ ] Long-term goals present (6-12 months)
|
||||
- [ ] Goals meet SMART criteria (see Section 2)
|
||||
- [ ] Patient-centered goals included
|
||||
- [ ] Goals are prioritized or organized
|
||||
|
||||
### ☐ Interventions
|
||||
- [ ] Pharmacological interventions specified
|
||||
- [ ] Non-pharmacological interventions included
|
||||
- [ ] Procedural interventions or referrals noted
|
||||
- [ ] Each intervention has clear rationale
|
||||
- [ ] Evidence-based or guideline-concordant
|
||||
|
||||
### ☐ Timeline and Schedule
|
||||
- [ ] Treatment phases with durations defined
|
||||
- [ ] Appointment frequency specified
|
||||
- [ ] Milestone assessments scheduled
|
||||
- [ ] Expected total treatment duration stated
|
||||
|
||||
### ☐ Monitoring Parameters
|
||||
- [ ] Clinical outcomes to track identified
|
||||
- [ ] Baseline values documented
|
||||
- [ ] Target values specified
|
||||
- [ ] Monitoring frequency defined
|
||||
- [ ] Assessment tools/scales named
|
||||
|
||||
### ☐ Expected Outcomes
|
||||
- [ ] Primary outcome measures stated
|
||||
- [ ] Success criteria defined
|
||||
- [ ] Timeline for improvement indicated
|
||||
- [ ] Criteria for treatment modification noted
|
||||
|
||||
### ☐ Follow-up Plan
|
||||
- [ ] Next appointment scheduled
|
||||
- [ ] Follow-up frequency specified
|
||||
- [ ] Communication plan outlined
|
||||
- [ ] Emergency contact procedures included
|
||||
|
||||
### ☐ Patient Education
|
||||
- [ ] Condition education documented
|
||||
- [ ] Self-management skills training noted
|
||||
- [ ] Warning signs communicated
|
||||
- [ ] Resources and support listed
|
||||
|
||||
### ☐ Risk Mitigation and Safety
|
||||
- [ ] Potential adverse effects identified
|
||||
- [ ] Safety monitoring plan included
|
||||
- [ ] Emergency procedures outlined
|
||||
- [ ] Complication prevention addressed
|
||||
|
||||
### ☐ Signature and Date
|
||||
- [ ] Provider signature line
|
||||
- [ ] Provider name and credentials
|
||||
- [ ] Date of plan
|
||||
- [ ] Patient acknowledgment (if applicable)
|
||||
|
||||
---
|
||||
|
||||
## Section 2: SMART Goals Quality
|
||||
|
||||
For each treatment goal, verify it meets SMART criteria:
|
||||
|
||||
### ☐ Specific
|
||||
- [ ] Goal clearly defines what will be accomplished
|
||||
- [ ] No vague language (e.g., "improve", "better")
|
||||
- [ ] Specific outcome stated
|
||||
|
||||
**Example**: "Reduce HbA1c from 8.5% to <7%" ✓
|
||||
**Not**: "Improve diabetes control" ✗
|
||||
|
||||
### ☐ Measurable
|
||||
- [ ] Quantifiable metric or observable criterion included
|
||||
- [ ] Baseline value documented
|
||||
- [ ] Target value specified
|
||||
|
||||
**Example**: "Walk 300 feet with walker independently" ✓
|
||||
**Not**: "Walk further" ✗
|
||||
|
||||
### ☐ Achievable
|
||||
- [ ] Realistic given patient's condition and capabilities
|
||||
- [ ] Resources available to support goal
|
||||
- [ ] Timeframe is reasonable
|
||||
- [ ] Treatment efficacy supports goal
|
||||
|
||||
**Example**: "Reduce pain from 7/10 to 4/10 in 6 weeks" ✓
|
||||
**Not**: "Eliminate all pain in 1 week" ✗
|
||||
|
||||
### ☐ Relevant
|
||||
- [ ] Aligned with patient values and priorities
|
||||
- [ ] Clinically meaningful
|
||||
- [ ] Addresses patient's functional limitations
|
||||
- [ ] Integrated with overall treatment objectives
|
||||
|
||||
**Example**: "Return to work with modifications within 3 months" ✓
|
||||
**Not**: "Lab value improvement" (if patient doesn't care about it) ✗
|
||||
|
||||
### ☐ Time-bound
|
||||
- [ ] Specific deadline or timeframe stated
|
||||
- [ ] Reassessment interval defined
|
||||
- [ ] Action frequency specified (if applicable)
|
||||
|
||||
**Example**: "Within 8 weeks" or "By month 3" ✓
|
||||
**Not**: "Eventually" or "Soon" ✗
|
||||
|
||||
---
|
||||
|
||||
## Section 3: Clinical Quality
|
||||
|
||||
### ☐ Evidence-Based Practice
|
||||
- [ ] Interventions based on current evidence
|
||||
- [ ] Clinical practice guidelines followed
|
||||
- [ ] Guideline deviations explained and justified
|
||||
- [ ] Literature or evidence cited (if formal plan)
|
||||
|
||||
### ☐ Medication Documentation (if applicable)
|
||||
- [ ] Generic drug names used
|
||||
- [ ] Specific dose, route, frequency documented
|
||||
- [ ] Indication/rationale provided for each medication
|
||||
- [ ] Adverse effects to monitor noted
|
||||
- [ ] Drug interactions considered
|
||||
- [ ] Titration plan included if applicable
|
||||
|
||||
### ☐ Assessment Tools
|
||||
- [ ] Validated assessment tools used when available
|
||||
- [ ] Tools appropriate for condition (PHQ-9, FIM, Berg, etc.)
|
||||
- [ ] Baseline scores documented
|
||||
- [ ] Target scores specified
|
||||
- [ ] Reassessment schedule defined
|
||||
|
||||
### ☐ Multidisciplinary Coordination (if applicable)
|
||||
- [ ] Roles of team members defined
|
||||
- [ ] Communication plan among providers specified
|
||||
- [ ] Care transitions addressed
|
||||
- [ ] Specialist recommendations integrated
|
||||
|
||||
### ☐ Preventive Care Integration
|
||||
- [ ] Age-appropriate screening included
|
||||
- [ ] Vaccination schedule noted
|
||||
- [ ] Lifestyle counseling documented
|
||||
- [ ] Health maintenance addressed
|
||||
|
||||
---
|
||||
|
||||
## Section 4: Patient-Centered Care
|
||||
|
||||
### ☐ Shared Decision-Making
|
||||
- [ ] Patient preferences documented
|
||||
- [ ] Treatment options discussed
|
||||
- [ ] Risks and benefits explained
|
||||
- [ ] Patient values incorporated into goals
|
||||
- [ ] Alternative treatments considered
|
||||
|
||||
### ☐ Health Literacy
|
||||
- [ ] Language appropriate for patient understanding
|
||||
- [ ] Medical jargon explained or avoided
|
||||
- [ ] Teach-back method used or planned
|
||||
- [ ] Written materials at appropriate reading level
|
||||
|
||||
### ☐ Cultural Competence
|
||||
- [ ] Cultural beliefs and practices considered
|
||||
- [ ] Language barriers addressed (interpreter if needed)
|
||||
- [ ] Cultural adaptations made when appropriate
|
||||
- [ ] Religious/spiritual preferences respected
|
||||
|
||||
### ☐ Social Determinants of Health
|
||||
- [ ] Social needs screened (food, housing, transportation)
|
||||
- [ ] Barriers to care identified
|
||||
- [ ] Community resources provided
|
||||
- [ ] Financial concerns addressed (medication costs, etc.)
|
||||
|
||||
### ☐ Patient Engagement
|
||||
- [ ] Patient actively involved in goal-setting
|
||||
- [ ] Self-management support provided
|
||||
- [ ] Patient education tailored to individual
|
||||
- [ ] Follow-up preferences considered
|
||||
|
||||
---
|
||||
|
||||
## Section 5: Safety and Risk Management
|
||||
|
||||
### ☐ Medication Safety
|
||||
- [ ] Allergy history documented
|
||||
- [ ] Polypharmacy reviewed (deprescribing considered)
|
||||
- [ ] High-risk medications monitored appropriately
|
||||
- [ ] Drug-drug interactions checked
|
||||
- [ ] Renal/hepatic dosing adjustments made if needed
|
||||
|
||||
### ☐ Fall Prevention (if relevant)
|
||||
- [ ] Fall risk assessed
|
||||
- [ ] Fall prevention strategies included
|
||||
- [ ] Environmental modifications recommended
|
||||
- [ ] Assistive devices prescribed
|
||||
|
||||
### ☐ Infection Prevention (if relevant)
|
||||
- [ ] Immunizations up to date
|
||||
- [ ] Prophylactic antibiotics if indicated
|
||||
- [ ] Infection signs and symptoms patient education
|
||||
|
||||
### ☐ Emergency Preparedness
|
||||
- [ ] Emergency warning signs clearly listed
|
||||
- [ ] When to call 911 specified
|
||||
- [ ] When to call provider defined
|
||||
- [ ] Emergency contact numbers provided
|
||||
|
||||
### ☐ Suicide/Violence Risk (mental health plans)
|
||||
- [ ] Risk assessment documented
|
||||
- [ ] Safety plan created if ideation present
|
||||
- [ ] Means restriction addressed
|
||||
- [ ] Crisis resources provided (988 lifeline)
|
||||
- [ ] Follow-up frequency appropriate for risk level
|
||||
|
||||
### ☐ Opioid Safety (pain management plans)
|
||||
- [ ] Opioid risk assessment completed (ORT, SOAPP)
|
||||
- [ ] Informed consent discussion documented
|
||||
- [ ] Treatment agreement signed
|
||||
- [ ] PDMP checked
|
||||
- [ ] Naloxone co-prescribed
|
||||
- [ ] UDS plan included
|
||||
|
||||
---
|
||||
|
||||
## Section 6: Regulatory Compliance
|
||||
|
||||
### ☐ HIPAA Compliance
|
||||
- [ ] Protected health information (PHI) safeguarded
|
||||
- [ ] De-identification per Safe Harbor method (if sharing)
|
||||
- [ ] All 18 HIPAA identifiers removed (if de-identified)
|
||||
- [ ] Minimum necessary principle followed
|
||||
|
||||
### ☐ Informed Consent
|
||||
- [ ] Consent discussion documented
|
||||
- [ ] Patient understanding verified
|
||||
- [ ] Risks and benefits explained
|
||||
- [ ] Alternative treatments discussed
|
||||
- [ ] Patient agreement documented
|
||||
|
||||
### ☐ Medical Necessity
|
||||
- [ ] Treatment medically necessary for diagnosis
|
||||
- [ ] Interventions appropriate for severity
|
||||
- [ ] Evidence supports treatment choices
|
||||
- [ ] Frequency and duration justified
|
||||
|
||||
### ☐ Billing and Coding
|
||||
- [ ] ICD-10 diagnosis codes included
|
||||
- [ ] CPT procedure codes (if procedures planned)
|
||||
- [ ] Documentation supports billing level
|
||||
- [ ] Medical necessity for services demonstrated
|
||||
|
||||
### ☐ Quality Measure Support
|
||||
- [ ] Elements support quality reporting (HEDIS, MIPS)
|
||||
- [ ] Chronic disease management protocols followed
|
||||
- [ ] Preventive care documented
|
||||
- [ ] Patient safety indicators addressed
|
||||
|
||||
### ☐ Specialty-Specific Regulations
|
||||
- [ ] 42 CFR Part 2 compliance (if substance use disorder treatment)
|
||||
- [ ] CDC opioid guidelines followed (if opioid prescription)
|
||||
- [ ] Joint Commission standards met (if applicable)
|
||||
- [ ] State-specific requirements addressed
|
||||
|
||||
---
|
||||
|
||||
## Section 7: Documentation Standards
|
||||
|
||||
### ☐ Clarity and Precision
|
||||
- [ ] Professional medical terminology used appropriately
|
||||
- [ ] Abbreviations defined on first use
|
||||
- [ ] No ambiguous language
|
||||
- [ ] Specific rather than vague descriptions
|
||||
|
||||
### ☐ Accuracy
|
||||
- [ ] Factually correct information
|
||||
- [ ] Current evidence-based recommendations
|
||||
- [ ] Correct medication dosing and frequencies
|
||||
- [ ] Proper ICD-10 and CPT coding
|
||||
|
||||
### ☐ Organization
|
||||
- [ ] Logical flow and structure
|
||||
- [ ] Consistent formatting
|
||||
- [ ] Easy to locate key information
|
||||
- [ ] Headings and sections clearly labeled
|
||||
|
||||
### ☐ Legibility (if handwritten or hybrid)
|
||||
- [ ] Handwriting legible
|
||||
- [ ] No unclear abbreviations
|
||||
- [ ] Typed portions clear
|
||||
- [ ] Signatures legible with printed name
|
||||
|
||||
### ☐ Authentication
|
||||
- [ ] Provider name clearly stated
|
||||
- [ ] Credentials included
|
||||
- [ ] Date of plan present
|
||||
- [ ] Signature obtained (electronic or handwritten)
|
||||
|
||||
---
|
||||
|
||||
## Section 8: Special Considerations by Plan Type
|
||||
|
||||
### For General Medical Plans:
|
||||
- [ ] Chronic disease management protocols followed
|
||||
- [ ] Guideline-based targets used (HbA1c, BP, lipids)
|
||||
- [ ] Medication regimen optimized
|
||||
- [ ] Comorbidities addressed
|
||||
- [ ] Preventive care integrated
|
||||
|
||||
### For Rehabilitation Plans:
|
||||
- [ ] Functional assessments with validated tools (FIM, Berg)
|
||||
- [ ] Impairment, activity, and participation goals included
|
||||
- [ ] Therapy frequency and duration specified
|
||||
- [ ] Home exercise program documented
|
||||
- [ ] DME and environmental modifications listed
|
||||
- [ ] Discharge criteria defined
|
||||
|
||||
### For Mental Health Plans:
|
||||
- [ ] DSM-5 diagnostic criteria met
|
||||
- [ ] Symptom severity assessed (PHQ-9, GAD-7, etc.)
|
||||
- [ ] Suicide/violence risk assessed
|
||||
- [ ] Safety plan created (if indicated)
|
||||
- [ ] Evidence-based psychotherapy specified
|
||||
- [ ] Medication trials and responses documented
|
||||
- [ ] Functional and recovery-oriented goals included
|
||||
|
||||
### For Chronic Disease Management Plans:
|
||||
- [ ] All active conditions prioritized
|
||||
- [ ] Medication synergies identified
|
||||
- [ ] Polypharmacy addressed
|
||||
- [ ] Care coordination plan clear
|
||||
- [ ] Registry/population health integration noted
|
||||
- [ ] Transition management included
|
||||
|
||||
### For Perioperative Plans:
|
||||
- [ ] Preoperative risk assessment (RCRI, ASA, Caprini)
|
||||
- [ ] Medical optimization documented
|
||||
- [ ] ERAS elements included (if applicable)
|
||||
- [ ] Postoperative milestones defined
|
||||
- [ ] Discharge criteria specified
|
||||
- [ ] VTE prophylaxis plan included
|
||||
|
||||
### For Pain Management Plans:
|
||||
- [ ] Comprehensive pain assessment (location, quality, intensity, impact)
|
||||
- [ ] Pain type classified (nociceptive, neuropathic, nociplastic)
|
||||
- [ ] Multimodal analgesia approach
|
||||
- [ ] Opioid risk assessment (if opioids considered)
|
||||
- [ ] Functional goals emphasized (not just pain scores)
|
||||
- [ ] Psychological screening and intervention included
|
||||
- [ ] CDC opioid guidelines followed (if prescribing)
|
||||
|
||||
---
|
||||
|
||||
## Section 9: Final Review
|
||||
|
||||
### ☐ Proofreading
|
||||
- [ ] Spelling and grammar checked
|
||||
- [ ] No typos or errors
|
||||
- [ ] Consistent terminology throughout
|
||||
- [ ] Patient name correct throughout (if not de-identified)
|
||||
|
||||
### ☐ Completeness Verification
|
||||
- [ ] All placeholder text replaced with patient-specific information
|
||||
- [ ] All bracketed [fields] customized
|
||||
- [ ] No "TBD" or "to be completed" items remaining
|
||||
- [ ] All required sections complete
|
||||
|
||||
### ☐ Quality Assurance
|
||||
- [ ] Plan reviewed by provider
|
||||
- [ ] Peer review completed (if applicable)
|
||||
- [ ] Compliance verification done
|
||||
- [ ] Automated checks run (if available scripts used)
|
||||
|
||||
### ☐ Patient Review Preparation
|
||||
- [ ] Patient-friendly summary prepared (if needed)
|
||||
- [ ] Patient education materials gathered
|
||||
- [ ] Consent forms ready for signature
|
||||
- [ ] Questions anticipated and prepared to address
|
||||
|
||||
---
|
||||
|
||||
## Scoring and Interpretation
|
||||
|
||||
**Total Items**: ~150 (varies by plan type)
|
||||
|
||||
### Scoring:
|
||||
- Count number of checked items
|
||||
- Calculate percentage: (Checked / Total) × 100
|
||||
|
||||
### Interpretation:
|
||||
- **95-100%**: Excellent - Plan meets highest quality standards
|
||||
- **85-94%**: Good - Plan is high quality with minor gaps
|
||||
- **70-84%**: Acceptable - Plan is adequate but has areas needing improvement
|
||||
- **<70%**: Needs Improvement - Significant gaps in quality or compliance
|
||||
|
||||
### Critical Items (Must Have):
|
||||
The following items are critical and must be present:
|
||||
- ✓ Patient identifier and de-identification notice
|
||||
- ✓ Primary diagnosis with ICD-10 code
|
||||
- ✓ At least 3 SMART goals
|
||||
- ✓ Interventions with rationales
|
||||
- ✓ Monitoring plan
|
||||
- ✓ Follow-up plan
|
||||
- ✓ Patient education
|
||||
- ✓ Safety/risk mitigation
|
||||
- ✓ Emergency procedures
|
||||
- ✓ Provider signature
|
||||
|
||||
If any critical item is missing, plan should not be finalized until corrected.
|
||||
|
||||
---
|
||||
|
||||
## Usage Instructions
|
||||
|
||||
1. **Review each section** systematically
|
||||
2. **Check boxes** as criteria are met
|
||||
3. **Note deficiencies** for correction
|
||||
4. **Calculate score** to assess overall quality
|
||||
5. **Address gaps** before finalizing
|
||||
6. **Document review** with reviewer name and date
|
||||
|
||||
**Reviewer**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
|
||||
|
||||
**Date Reviewed**: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
|
||||
|
||||
**Score**: \_\_\_\_\_% (\_\_\_\_ items checked / \_\_\_\_ total items)
|
||||
|
||||
**Status**:
|
||||
- [ ] Approved for use
|
||||
- [ ] Approved with minor revisions
|
||||
- [ ] Requires significant revision
|
||||
- [ ] Not approved
|
||||
|
||||
**Comments/Recommendations**:
|
||||
|
||||
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
|
||||
|
||||
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
|
||||
|
||||
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
|
||||
|
||||
---
|
||||
|
||||
**Document Version**: 1.0
|
||||
**Last Updated**: January 2025
|
||||
**Next Review**: Annually or with guideline updates
|
||||
|
||||
756
skills/treatment-plans/assets/rehabilitation_treatment_plan.tex
Normal file
756
skills/treatment-plans/assets/rehabilitation_treatment_plan.tex
Normal file
@@ -0,0 +1,756 @@
|
||||
% Rehabilitation Treatment Plan Template
|
||||
% For physical therapy, occupational therapy, and rehabilitation services
|
||||
% Last updated: 2025
|
||||
|
||||
\documentclass[11pt,letterpaper]{article}
|
||||
|
||||
% Packages
|
||||
\usepackage[top=1in,bottom=1in,left=1in,right=1in]{geometry}
|
||||
\usepackage{amsmath,amssymb}
|
||||
\usepackage[utf8]{inputenc}
|
||||
\usepackage{graphicx}
|
||||
\usepackage{array}
|
||||
\usepackage{longtable}
|
||||
\usepackage{booktabs}
|
||||
\usepackage{enumitem}
|
||||
\usepackage{xcolor}
|
||||
\usepackage{fancyhdr}
|
||||
\usepackage{lastpage}
|
||||
\usepackage{tabularx}
|
||||
\usepackage{multirow}
|
||||
\usepackage[most]{tcolorbox}
|
||||
|
||||
% Header and footer
|
||||
\pagestyle{fancy}
|
||||
\fancyhf{}
|
||||
\lhead{Rehabilitation Treatment Plan}
|
||||
\rhead{Page \thepage\ of \pageref{LastPage}}
|
||||
\lfoot{Date Created: \today}
|
||||
\rfoot{Confidential Patient Information}
|
||||
|
||||
% Title formatting
|
||||
\usepackage{titlesec}
|
||||
\titleformat{\section}{\large\bfseries}{\thesection}{1em}{}
|
||||
\titleformat{\subsection}{\normalsize\bfseries}{\thesubsection}{1em}{}
|
||||
|
||||
\begin{document}
|
||||
|
||||
% Title
|
||||
\begin{center}
|
||||
{\Large\bfseries REHABILITATION TREATMENT PLAN}\\[0.5em]
|
||||
{\large Physical Therapy | Occupational Therapy | Speech-Language Pathology}\\[0.5em]
|
||||
\rule{\textwidth}{1pt}
|
||||
\end{center}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== TREATMENT PLAN HIGHLIGHTS (Foundation Medicine Model) =====
|
||||
\begin{tcolorbox}[colback=green!5!white,colframe=green!75!black,title=\textbf{TREATMENT PLAN HIGHLIGHTS},fonttitle=\bfseries\large]
|
||||
|
||||
\textbf{Key Diagnosis:} [Primary condition requiring rehabilitation - e.g., Post-stroke hemiparesis, Total knee replacement]
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Primary Functional Goals:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item [Goal 1 - e.g., Independent ambulation with assistive device within 8 weeks]
|
||||
\item [Goal 2 - e.g., Return to independent ADLs (bathing, dressing) within 12 weeks]
|
||||
\item [Goal 3 - e.g., Improve upper extremity strength to 4/5 for functional tasks]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Main Interventions:}
|
||||
\begin{itemize}[leftmargin=*,itemsep=0pt]
|
||||
\item \textit{Physical Therapy:} [Focus - e.g., Gait training, strengthening, balance exercises 3x/week]
|
||||
\item \textit{Occupational Therapy:} [Focus - e.g., ADL training, adaptive equipment, 2x/week]
|
||||
\item \textit{Home Exercise Program:} [Key exercises - e.g., Daily strengthening and ROM exercises]
|
||||
\end{itemize}
|
||||
|
||||
\vspace{0.3em}
|
||||
\textbf{Timeline:} [Duration - e.g., Acute phase (4 weeks), Active rehab (8 weeks), Maintenance (ongoing)]
|
||||
|
||||
\end{tcolorbox}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
% ===== SECTION 1: PATIENT INFORMATION =====
|
||||
\section*{1. Patient Information}
|
||||
|
||||
\textbf{HIPAA Notice}: De-identify per Safe Harbor method. Remove all 18 HIPAA identifiers before sharing.
|
||||
|
||||
\vspace{0.5em}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|}
|
||||
\hline
|
||||
\textbf{Patient ID} & [De-identified code, e.g., PT-RH-001] \\ \hline
|
||||
\textbf{Age Range} & [e.g., 65-70 years] \\ \hline
|
||||
\textbf{Sex} & [Male/Female/Other] \\ \hline
|
||||
\textbf{Date of Plan} & [Month/Year only] \\ \hline
|
||||
\textbf{Referring Provider} & [Name, Credentials] \\ \hline
|
||||
\textbf{Primary Therapist} & [PT/OT/SLP Name, Credentials] \\ \hline
|
||||
\textbf{Facility} & [Rehabilitation center/Clinic name] \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{1em}
|
||||
|
||||
\subsection*{Diagnosis and Medical History}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Primary Diagnosis}: [e.g., Right hip fracture status post ORIF] (ICD-10: [code])
|
||||
\item \textbf{Secondary Diagnoses}:
|
||||
\begin{itemize}
|
||||
\item [e.g., Osteoporosis] (ICD-10: [code])
|
||||
\item [e.g., Hypertension] (ICD-10: [code])
|
||||
\item [Additional relevant conditions]
|
||||
\end{itemize}
|
||||
\item \textbf{Date of Injury/Surgery}: [Month/Year]
|
||||
\item \textbf{Surgical Procedure}: [e.g., Open reduction internal fixation right hip]
|
||||
\item \textbf{Precautions/Restrictions}: [e.g., Weight-bearing as tolerated, hip flexion $<$90 degrees]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Current Medications}
|
||||
|
||||
Medications affecting rehabilitation:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Pain Management}: [e.g., Oxycodone 5mg Q6H PRN - may affect alertness]
|
||||
\item \textbf{Anticoagulation}: [e.g., Enoxaparin 40mg daily - fall precautions]
|
||||
\item \textbf{Other Relevant Medications}: [e.g., Beta-blocker - monitor HR during exercise]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Living Situation and Support}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Living Environment}: [e.g., Two-story home, bedroom upstairs, 4 steps to entry]
|
||||
\item \textbf{Social Support}: [e.g., Lives with spouse, adult children nearby]
|
||||
\item \textbf{Prior Functional Level}: [e.g., Independent in all ADLs, community ambulation]
|
||||
\item \textbf{Occupation/Activities}: [e.g., Retired teacher, enjoys gardening and walking]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 2: FUNCTIONAL ASSESSMENT =====
|
||||
\section*{2. Initial Functional Assessment}
|
||||
|
||||
\subsection*{2.1 Functional Independence Measure (FIM) or Similar}
|
||||
|
||||
\textbf{Date of Assessment}: [Date]
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|c|c|X|}
|
||||
\hline
|
||||
\textbf{Domain} & \textbf{Score} & \textbf{Goal} & \textbf{Notes} \\ \hline
|
||||
Self-Care & [e.g., 28/42] & [35/42] & Requires assist with lower body dressing, bathing \\ \hline
|
||||
Sphincter Control & [42/42] & [42/42] & Independent \\ \hline
|
||||
Transfers & [e.g., 12/21] & [18/21] & Moderate assist bed/chair, toilet \\ \hline
|
||||
Locomotion & [e.g., 8/14] & [12/14] & Contact guard ambulation 50ft with walker \\ \hline
|
||||
Communication & [14/14] & [14/14] & Independent \\ \hline
|
||||
Social Cognition & [21/21] & [21/21] & Independent \\ \hline
|
||||
\textbf{TOTAL FIM} & \textbf{[125/126]} & \textbf{[142/126]} & \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\vspace{0.5em}
|
||||
\textit{FIM Scoring: 7=Complete Independence, 6=Modified Independence, 5=Supervision, 4=Minimal Assist, 3=Moderate Assist, 2=Maximal Assist, 1=Total Assist}
|
||||
|
||||
\subsection*{2.2 Physical Therapy Assessment}
|
||||
|
||||
\textbf{Range of Motion}:
|
||||
\begin{longtable}{|l|c|c|c|}
|
||||
\hline
|
||||
\textbf{Joint/Motion} & \textbf{Baseline} & \textbf{Goal} & \textbf{Normal Range} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Joint/Motion} & \textbf{Baseline} & \textbf{Goal} & \textbf{Normal Range} \\ \hline
|
||||
\endhead
|
||||
Right hip flexion & 70° (pain at end range) & 110° pain-free & 120° \\ \hline
|
||||
Right hip extension & 5° & 15° & 20° \\ \hline
|
||||
Right hip abduction & 20° & 35° & 45° \\ \hline
|
||||
Right knee flexion & 100° & 125° & 130° \\ \hline
|
||||
Right ankle DF/PF & 5°/35° & 10°/40° & 15°/50° \\ \hline
|
||||
[Additional joints] & & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{Muscle Strength (Manual Muscle Testing - MMT)}:
|
||||
\begin{longtable}{|l|c|c|}
|
||||
\hline
|
||||
\textbf{Muscle Group} & \textbf{Baseline} & \textbf{Goal} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Muscle Group} & \textbf{Baseline} & \textbf{Goal} \\ \hline
|
||||
\endhead
|
||||
Right hip flexors & 3/5 (fair) & 4+/5 (good+) \\ \hline
|
||||
Right hip extensors & 3/5 (fair) & 4+/5 (good+) \\ \hline
|
||||
Right hip abductors & 2+/5 (poor+) & 4/5 (good) \\ \hline
|
||||
Right quadriceps & 4-/5 (good-) & 5/5 (normal) \\ \hline
|
||||
Right ankle DF/PF & 4/5 / 4/5 & 5/5 / 5/5 \\ \hline
|
||||
Core stability & Fair & Good \\ \hline
|
||||
[Additional muscles] & & \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textit{MMT Scale: 5=Normal, 4=Good, 3=Fair, 2=Poor, 1=Trace, 0=Zero}
|
||||
|
||||
\textbf{Balance Assessment}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Berg Balance Scale}: [e.g., 38/56 - Moderate fall risk]
|
||||
\item \textbf{Goal Berg Score}: [e.g., $>$45/56 - Low fall risk]
|
||||
\item \textbf{Static Standing Balance}: [e.g., Able to stand 30 sec with walker, not independent]
|
||||
\item \textbf{Dynamic Balance}: [e.g., Unable to step over obstacles safely]
|
||||
\item \textbf{Single Leg Stance}: [e.g., Unable, requires support]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Gait Assessment}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Assistive Device}: [e.g., Front-wheeled walker]
|
||||
\item \textbf{Weight-Bearing Status}: [e.g., WBAT (weight-bearing as tolerated)]
|
||||
\item \textbf{Gait Distance}: [e.g., 50 feet with contact guard, requires 1 rest break]
|
||||
\item \textbf{Gait Speed}: [e.g., 0.4 m/s (severely impaired, normal $>$1.0 m/s)]
|
||||
\item \textbf{Gait Deviations}: [e.g., Shortened stance phase right, Trendelenburg gait, decreased step length]
|
||||
\item \textbf{Stairs}: [e.g., Unable to attempt, 4 steps required for home access]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Endurance}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{6-Minute Walk Test}: [e.g., 150 feet - severely impaired]
|
||||
\item \textbf{Goal Distance}: [e.g., 300+ feet]
|
||||
\item \textbf{Perceived Exertion}: [e.g., 5/10 after 50 feet]
|
||||
\item \textbf{Vital Signs Response}: [e.g., HR increases 85→105, appropriate response]
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Pain Assessment}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Pain Location}: [e.g., Right hip, groin region]
|
||||
\item \textbf{Pain at Rest}: [e.g., 2/10]
|
||||
\item \textbf{Pain with Activity}: [e.g., 6/10 with weight-bearing, 4/10 with ROM]
|
||||
\item \textbf{Pain Impact}: [e.g., Limits therapy participation, improves with rest]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.3 Occupational Therapy Assessment}
|
||||
|
||||
\textbf{Activities of Daily Living (ADLs)}:
|
||||
\begin{longtable}{|l|c|X|}
|
||||
\hline
|
||||
\textbf{Activity} & \textbf{Level} & \textbf{Description} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Activity} & \textbf{Level} & \textbf{Description} \\ \hline
|
||||
\endhead
|
||||
Bathing & Mod A & Requires assist entering/exiting shower, reaching lower extremities \\ \hline
|
||||
Dressing - Upper Body & I & Independent \\ \hline
|
||||
Dressing - Lower Body & Mod A & Requires assist donning socks, shoes, pants due to hip precautions \\ \hline
|
||||
Toileting & Min A & Requires assist with clothing management \\ \hline
|
||||
Grooming & I & Independent \\ \hline
|
||||
Feeding & I & Independent \\ \hline
|
||||
Functional Mobility & CG & Contact guard for bed mobility, transfers \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textit{I=Independent, SV=Supervision, CG=Contact Guard, Min A=Minimal Assist, Mod A=Moderate Assist, Max A=Maximal Assist}
|
||||
|
||||
\textbf{Instrumental Activities of Daily Living (IADLs)}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Meal Preparation}: Not assessed, not safe for standing tasks currently
|
||||
\item \textbf{Housekeeping}: Dependent, unable to perform
|
||||
\item \textbf{Laundry}: Dependent
|
||||
\item \textbf{Shopping}: Dependent
|
||||
\item \textbf{Home Management}: Requires complete assistance
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Upper Extremity Function}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Grip Strength}: Right [kg], Left [kg] (compared to normative data)
|
||||
\item \textbf{Coordination}: [e.g., Within normal limits bilaterally]
|
||||
\item \textbf{Sensation}: [e.g., Intact to light touch, proprioception]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.4 Cognitive and Perceptual Assessment}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Alertness/Orientation}: [e.g., Alert, oriented x3]
|
||||
\item \textbf{Memory}: [e.g., Intact for short and long-term]
|
||||
\item \textbf{Safety Awareness}: [e.g., Good insight into limitations, follows precautions]
|
||||
\item \textbf{Executive Function}: [e.g., Able to problem-solve, sequence tasks appropriately]
|
||||
\item \textbf{Visual-Perceptual Skills}: [e.g., Within normal limits]
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{2.5 Environmental Assessment}
|
||||
|
||||
\textbf{Home Safety Concerns}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item 4 steps to enter home - needs stair training
|
||||
\item Bedroom/bathroom upstairs - may need temporary bedroom on main floor
|
||||
\item Shower stall (no tub) - needs shower chair, grab bars
|
||||
\item Scatter rugs - fall hazard, recommend removal
|
||||
\item Adequate lighting - satisfactory
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 3: REHABILITATION GOALS =====
|
||||
\section*{3. Rehabilitation Goals (SMART Format)}
|
||||
|
||||
\subsection*{3.1 Short-Term Goals (2-4 weeks)}
|
||||
|
||||
\textbf{Impairment-Level Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Range of Motion}: Increase right hip flexion from 70° to 90° pain-free within 2 weeks to improve functional mobility.
|
||||
|
||||
\item \textbf{Strength}: Improve right hip abductor strength from 2+/5 to 3+/5 within 3 weeks to reduce Trendelenburg gait.
|
||||
|
||||
\item \textbf{Balance}: Increase Berg Balance Scale from 38/56 to 42/56 within 4 weeks to reduce fall risk.
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Activity-Level Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Ambulation}: Ambulate 150 feet with front-wheeled walker, supervision level, within 3 weeks.
|
||||
|
||||
\item \textbf{Transfers}: Perform bed-to-chair and toilet transfers with supervision (no physical assist) within 2 weeks.
|
||||
|
||||
\item \textbf{Stairs}: Ascend/descend 4 stairs with handrail and supervision within 4 weeks for home access.
|
||||
|
||||
\item \textbf{Lower Body Dressing}: Don socks and shoes with adaptive equipment (reacher, sock aid) with minimal assist within 3 weeks.
|
||||
|
||||
\item \textbf{Bathing}: Shower independently using shower chair and grab bars with setup assistance within 4 weeks.
|
||||
\end{enumerate}
|
||||
|
||||
\subsection*{3.2 Long-Term Goals (6-12 weeks)}
|
||||
|
||||
\textbf{Participation-Level Goals}:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item \textbf{Community Ambulation}: Walk independently 300+ feet with assistive device on varied terrain within 8 weeks to enable community outings.
|
||||
|
||||
\item \textbf{ADL Independence}: Achieve independence in all basic ADLs (bathing, dressing, toileting, transfers) within 8 weeks for safe home discharge.
|
||||
|
||||
\item \textbf{Home Management}: Return to light homemaking tasks (meal prep, laundry) with modified techniques within 12 weeks.
|
||||
|
||||
\item \textbf{Recreational Activities}: Resume gardening with adaptive techniques and equipment within 12 weeks.
|
||||
|
||||
\item \textbf{Fall Prevention}: Demonstrate safety awareness and fall prevention strategies for independent home functioning within 8 weeks.
|
||||
\end{enumerate}
|
||||
|
||||
\textbf{Discharge Goals}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Safe discharge home with appropriate DME (durable medical equipment)
|
||||
\item Independent or supervision level for all ADLs
|
||||
\item Community ambulation with assistive device
|
||||
\item Patient and family educated on home exercise program
|
||||
\item Fall risk minimized with environmental modifications
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{3.3 Patient-Centered Goals}
|
||||
|
||||
Patient's top priorities:
|
||||
\begin{enumerate}[leftmargin=*]
|
||||
\item "I want to go home and not need help from my family"
|
||||
\item "I want to be able to go to the grocery store again"
|
||||
\item "I want to get back to my garden this spring"
|
||||
\end{enumerate}
|
||||
|
||||
% ===== SECTION 4: TREATMENT INTERVENTIONS =====
|
||||
\section*{4. Treatment Interventions}
|
||||
|
||||
\subsection*{4.1 Physical Therapy Interventions}
|
||||
|
||||
\textbf{Frequency}: 3 sessions per week, 45-60 minutes per session, for 8-12 weeks
|
||||
|
||||
\textbf{Therapeutic Exercise}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Strengthening}:
|
||||
\begin{itemize}
|
||||
\item Hip abduction in sidelying with resistance band: 3 sets x 10 reps
|
||||
\item Hip extension prone: 3 sets x 10 reps
|
||||
\item Quadriceps sets and straight leg raises: 3 sets x 10 reps
|
||||
\item Standing hip abduction at parallel bars: 2 sets x 10 reps
|
||||
\item Step-ups (2-inch platform progressing to 6-inch): 2 sets x 10 reps
|
||||
\item Squats (partial, with walker for support): 2 sets x 10 reps
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Range of Motion}:
|
||||
\begin{itemize}
|
||||
\item Active-assisted hip flexion supine: 3 sets x 10 reps
|
||||
\item Hip flexor stretching (modified, respecting precautions): 3 x 30 sec holds
|
||||
\item Ankle pumps and circles: 3 sets x 10 reps
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Core Stabilization}:
|
||||
\begin{itemize}
|
||||
\item Abdominal bracing: 10 x 10 sec holds
|
||||
\item Pelvic tilts: 2 sets x 10 reps
|
||||
\item Dead bug progression (modified): 2 sets x 8 reps
|
||||
\end{itemize}
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Balance Training}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Static standing balance exercises at parallel bars
|
||||
\item Weight shifting activities (anterior-posterior, medial-lateral)
|
||||
\item Tandem stance progression
|
||||
\item Single-leg stance (holding support as needed)
|
||||
\item Reaching activities outside base of support
|
||||
\item Step-over obstacles
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Gait Training}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Gait training with front-wheeled walker on level surfaces
|
||||
\item Focus on step length symmetry, heel strike, push-off
|
||||
\item Progress from contact guard to supervision to modified independence
|
||||
\item Advance distance as tolerated (goal 300+ feet)
|
||||
\item Outdoor gait training on varied terrain (grass, gravel, curbs)
|
||||
\item Reduce assistive device as appropriate (walker → cane → no device)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Stair Training}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Stair negotiation with handrail (step-to pattern initially)
|
||||
\item 4 steps ascending/descending to match home environment
|
||||
\item Progress to step-over-step pattern
|
||||
\item Practice with carrying objects
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Modalities (as indicated)}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Ice after therapy sessions for pain management
|
||||
\item Electrical stimulation for hip abductor muscle re-education (if indicated)
|
||||
\item Ultrasound for soft tissue mobility (if indicated)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Patient Education}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Hip precautions education and review
|
||||
\item Fall prevention strategies
|
||||
\item Proper use of assistive device
|
||||
\item Pain management techniques
|
||||
\item Activity pacing and energy conservation
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.2 Occupational Therapy Interventions}
|
||||
|
||||
\textbf{Frequency}: 3 sessions per week, 45 minutes per session, for 6-8 weeks
|
||||
|
||||
\textbf{ADL Training}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Bathing}: Practice shower transfers with grab bars and shower chair, long-handled sponge technique
|
||||
\item \textbf{Lower Body Dressing}: Training with reacher, sock aid, elastic shoelaces, dressing stick
|
||||
\item \textbf{Toileting}: Practice with raised toilet seat and grab bars
|
||||
\item \textbf{Bed Mobility}: Log-roll technique, use of bed rail if needed
|
||||
\item \textbf{Kitchen Tasks}: Safe standing tolerance, use of walker basket to carry items
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Adaptive Equipment Training}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Reacher (32-inch) for dressing, picking up objects
|
||||
\item Sock aid and dressing stick for lower extremity dressing
|
||||
\item Long-handled shoe horn
|
||||
\item Long-handled sponge/bath brush
|
||||
\item Shower chair with back
|
||||
\item Raised toilet seat with arms
|
||||
\item Bedside commode (if bedroom upstairs initially)
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Home Management Training}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Light meal preparation (seated when possible)
|
||||
\item Laundry (modified techniques, avoid lifting heavy baskets)
|
||||
\item Safe reaching and bending techniques
|
||||
\item Organization strategies to minimize unnecessary walking
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Upper Extremity Strengthening}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Therapeutic putty for grip strength
|
||||
\item Weighted exercises for shoulder stability (needed for walker use)
|
||||
\item Fine motor coordination activities
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Energy Conservation and Work Simplification}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Activity pacing strategies
|
||||
\item Prioritization of daily tasks
|
||||
\item Use of rest breaks
|
||||
\item Organization to reduce unnecessary steps
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.3 Home Exercise Program (HEP)}
|
||||
|
||||
Patient provided with illustrated HEP to perform daily at home:
|
||||
|
||||
\begin{longtable}{|p{4cm}|p{4cm}|p{5cm}|}
|
||||
\hline
|
||||
\textbf{Exercise} & \textbf{Dosage} & \textbf{Instructions} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Exercise} & \textbf{Dosage} & \textbf{Instructions} \\ \hline
|
||||
\endhead
|
||||
Ankle pumps & 3 x 10, 3x daily & Seated or lying, point toes up/down \\ \hline
|
||||
Quadriceps sets & 3 x 10, 2x daily & Tighten thigh muscle, hold 5 sec \\ \hline
|
||||
Hip abduction sidelying & 2 x 10, 1x daily & Lift top leg, hold 2 sec, lower slowly \\ \hline
|
||||
Sit-to-stand & 2 x 10, 2x daily & Use walker, stand fully, sit slowly \\ \hline
|
||||
Standing hip flexion & 2 x 10, 1x daily & Lift knee (respect 90° precaution) \\ \hline
|
||||
Balance - standing & 3 x 30 sec, 2x daily & Stand at counter, reduce hand support as able \\ \hline
|
||||
Walking & 10 min, 2-3x daily & With walker, gradually increase distance \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\textbf{HEP Instructions}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Perform exercises on non-therapy days
|
||||
\item Stop if pain exceeds 4/10
|
||||
\item Maintain hip precautions at all times
|
||||
\item Progress per therapist instruction only
|
||||
\item Record completion in exercise log
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{4.4 Durable Medical Equipment (DME)}
|
||||
|
||||
\textbf{Recommended Equipment}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Front-wheeled walker (standard adult)
|
||||
\item Shower chair with back (adjustable height)
|
||||
\item Grab bars for shower (2 bars - vertical and horizontal)
|
||||
\item Raised toilet seat with arms
|
||||
\item Reacher (32-inch)
|
||||
\item Sock aid
|
||||
\item Long-handled shoe horn
|
||||
\item Long-handled sponge
|
||||
\item Bedside commode (if needed initially)
|
||||
\item Non-slip bath mat
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 5: TREATMENT SCHEDULE =====
|
||||
\section*{5. Treatment Schedule and Timeline}
|
||||
|
||||
\subsection*{Treatment Phases}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|l|X|}
|
||||
\hline
|
||||
\textbf{Phase} & \textbf{Duration} & \textbf{Focus} \\ \hline
|
||||
Acute/Early & Weeks 1-2 & Pain management, basic mobility, ADL training with equipment, safety \\ \hline
|
||||
Intermediate & Weeks 3-6 & Strength/ROM progression, advanced balance, stair training, ADL refinement \\ \hline
|
||||
Advanced & Weeks 7-10 & Community ambulation, IADL training, HEP independence, discharge prep \\ \hline
|
||||
Transition & Weeks 11-12 & Reduce frequency, monitor independence, finalize home setup \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Session Frequency and Duration}
|
||||
|
||||
\begin{tabularx}{\textwidth}{|l|X|X|}
|
||||
\hline
|
||||
\textbf{Discipline} & \textbf{Frequency} & \textbf{Duration} \\ \hline
|
||||
Physical Therapy & 3x/week & 45-60 min/session, 8-12 weeks total \\ \hline
|
||||
Occupational Therapy & 3x/week & 45 min/session, 6-8 weeks total \\ \hline
|
||||
Home Exercise Program & Daily (non-therapy days) & 30 min/day \\ \hline
|
||||
\end{tabularx}
|
||||
|
||||
\subsection*{Progress Assessments}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Weekly}: Informal progress monitoring, pain levels, exercise tolerance
|
||||
\item \textbf{Biweekly}: Reassess key impairments (ROM, strength, balance measures)
|
||||
\item \textbf{Week 4}: Formal reassessment, FIM score, goal progress review, plan modification if needed
|
||||
\item \textbf{Week 8}: Comprehensive reassessment, discharge planning, final goal review
|
||||
\item \textbf{Discharge}: Final outcomes documentation, HEP review, follow-up recommendations
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 6: OUTCOME MEASURES =====
|
||||
\section*{6. Outcome Measures and Monitoring}
|
||||
|
||||
\subsection*{Standardized Assessments}
|
||||
|
||||
\begin{longtable}{|p{4.5cm}|p{3cm}|p{3cm}|p{3cm}|}
|
||||
\hline
|
||||
\textbf{Measure} & \textbf{Baseline} & \textbf{Goal} & \textbf{Frequency} \\ \hline
|
||||
\endfirsthead
|
||||
\hline
|
||||
\textbf{Measure} & \textbf{Baseline} & \textbf{Goal} & \textbf{Frequency} \\ \hline
|
||||
\endhead
|
||||
FIM Score & [125/126] & [142/126] & Week 0, 4, 8, discharge \\ \hline
|
||||
Berg Balance Scale & [38/56] & [$>$45/56] & Week 0, 4, 8, discharge \\ \hline
|
||||
6-Minute Walk Test & [150 feet] & [$>$300 feet] & Week 0, 4, 8, discharge \\ \hline
|
||||
Gait Speed & [0.4 m/s] & [$>$0.8 m/s] & Week 0, 4, 8, discharge \\ \hline
|
||||
Pain (NRS 0-10) & [6/10 with activity] & [$<$3/10] & Each session \\ \hline
|
||||
ROM - Hip Flexion & [70°] & [110°] & Biweekly \\ \hline
|
||||
Strength - Hip Abductors & [2+/5] & [4/5] & Biweekly \\ \hline
|
||||
\end{longtable}
|
||||
|
||||
\subsection*{Progress Indicators}
|
||||
|
||||
\textbf{Positive Progress}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Increasing ambulation distance
|
||||
\item Reduced level of assistance for ADLs
|
||||
\item Improved balance scores
|
||||
\item Decreased pain with activity
|
||||
\item Increased strength/ROM measurements
|
||||
\item Patient confidence and self-efficacy improving
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Barriers to Progress}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Inadequate pain control
|
||||
\item Poor therapy attendance or compliance
|
||||
\item Medical complications or setbacks
|
||||
\item Psychosocial factors (depression, anxiety, lack of support)
|
||||
\item Cognitive impairment affecting learning
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 7: EXPECTED OUTCOMES =====
|
||||
\section*{7. Expected Outcomes and Prognosis}
|
||||
|
||||
\subsection*{Rehabilitation Potential}
|
||||
|
||||
\textbf{Overall Prognosis}: [e.g., Good] - Patient is motivated, has good social support, no significant cognitive impairment, and appropriate medical management.
|
||||
|
||||
\textbf{Expected Functional Outcome}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Independent or supervision level for all basic ADLs
|
||||
\item Community ambulation with assistive device (walker or cane)
|
||||
\item Ability to negotiate stairs for home access
|
||||
\item Safe discharge home with DME and environmental modifications
|
||||
\item Return to modified IADL participation
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Timeline for Key Milestones}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Week 2}: Transfers with supervision, basic ADLs with minimal assist
|
||||
\item \textbf{Week 4}: Ambulation 150 feet with walker/supervision, improved pain control
|
||||
\item \textbf{Week 6}: Stairs with handrail/supervision, ADLs mostly independent with equipment
|
||||
\item \textbf{Week 8}: Community ambulation 300+ feet, all ADLs independent, ready for discharge
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 8: FOLLOW-UP AND DISCHARGE PLANNING =====
|
||||
\section*{8. Follow-Up and Discharge Planning}
|
||||
|
||||
\subsection*{Discharge Criteria}
|
||||
|
||||
Patient ready for discharge when:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Safe for home environment (with or without DME)
|
||||
\item Independent or supervision level for ADLs
|
||||
\item Patient/caregiver educated on HEP and safety
|
||||
\item DME obtained and home modifications completed
|
||||
\item Functional goals achieved or plateau reached
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Discharge Recommendations}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Continue HEP as prescribed, progress as tolerated
|
||||
\item Follow up with orthopedic surgeon at [timeframe]
|
||||
\item Consider outpatient therapy if continued progress expected
|
||||
\item Home health PT/OT if unable to access outpatient services
|
||||
\item Transition to community exercise program (e.g., senior center, aquatics)
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Home Modifications and Safety}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Install grab bars in shower (vertical and horizontal)
|
||||
\item Ensure adequate lighting, especially on stairs
|
||||
\item Remove scatter rugs and clutter
|
||||
\item Consider temporary bedroom on main floor if stairs difficult
|
||||
\item Rearrange furniture to create clear pathways
|
||||
\item Store frequently used items at accessible heights
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Follow-Up Communication}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Progress reports sent to referring physician biweekly
|
||||
\item Final discharge summary to all providers
|
||||
\item Home safety assessment completed
|
||||
\item DME delivered and training completed
|
||||
\item Emergency contact: Therapy department [phone]
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 9: SAFETY AND PRECAUTIONS =====
|
||||
\section*{9. Safety Considerations and Precautions}
|
||||
|
||||
\subsection*{Medical Precautions}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Hip Precautions} (post-ORIF):
|
||||
\begin{itemize}
|
||||
\item No hip flexion $>$90 degrees for 6-8 weeks
|
||||
\item No hip adduction past midline
|
||||
\item No internal rotation
|
||||
\item Sleep with abduction pillow
|
||||
\item Use elevated toilet seat and shower chair
|
||||
\end{itemize}
|
||||
|
||||
\item \textbf{Weight-Bearing Status}: [e.g., WBAT - Weight-bearing as tolerated]
|
||||
|
||||
\item \textbf{Anticoagulation}: On enoxaparin - use fall precautions, report bruising/bleeding
|
||||
|
||||
\item \textbf{Pain Management}: Opioid use may cause drowsiness - schedule therapy before pain medication if possible
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Fall Risk Management}
|
||||
|
||||
\textbf{Fall Risk Factors}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Recent surgery/hospitalization
|
||||
\item Impaired balance (Berg 38/56)
|
||||
\item Use of walker
|
||||
\item Pain medication (opioids)
|
||||
\item Environmental hazards at home
|
||||
\end{itemize}
|
||||
|
||||
\textbf{Fall Prevention Strategies}:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Consistent use of walker
|
||||
\item Non-slip footwear with closed heel
|
||||
\item Call for assistance for transfers initially
|
||||
\item Adequate lighting
|
||||
\item Avoid carrying items while walking (use walker basket)
|
||||
\item Balance training in therapy
|
||||
\item Home safety modifications
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Contraindications to Treatment}
|
||||
|
||||
Hold or modify therapy if:
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item Fever $>$101°F or signs of infection
|
||||
\item Uncontrolled pain ($>$7/10)
|
||||
\item Excessive swelling, warmth, redness at surgical site
|
||||
\item Chest pain, severe shortness of breath
|
||||
\item Dizziness, lightheadedness, abnormal vital signs
|
||||
\item Patient refusal or excessive fatigue
|
||||
\end{itemize}
|
||||
|
||||
\subsection*{Emergency Procedures}
|
||||
|
||||
\begin{itemize}[leftmargin=*]
|
||||
\item \textbf{Fall During Therapy}: Assess for injury, vital signs, notify physician, incident report
|
||||
\item \textbf{Chest Pain/SOB}: Stop activity, call 911, notify physician
|
||||
\item \textbf{Excessive Pain}: Stop activity, apply ice, notify physician, reassess treatment plan
|
||||
\end{itemize}
|
||||
|
||||
% ===== SECTION 10: PROVIDER SIGNATURE =====
|
||||
\vspace{2em}
|
||||
|
||||
\section*{10. Rehabilitation Team Signatures}
|
||||
|
||||
\textbf{Physical Therapist}:\\[0.5em]
|
||||
Signature: \rule{6cm}{0.5pt} \quad Date: \rule{3cm}{0.5pt}\\
|
||||
Name/Credentials: \rule{6cm}{0.5pt}\\[1em]
|
||||
|
||||
\textbf{Occupational Therapist}:\\[0.5em]
|
||||
Signature: \rule{6cm}{0.5pt} \quad Date: \rule{3cm}{0.5pt}\\
|
||||
Name/Credentials: \rule{6cm}{0.5pt}\\[1em]
|
||||
|
||||
\textbf{Referring Physician Approval}:\\[0.5em]
|
||||
Signature: \rule{6cm}{0.5pt} \quad Date: \rule{3cm}{0.5pt}\\
|
||||
Name/Credentials: \rule{6cm}{0.5pt}\\
|
||||
|
||||
\vspace{2em}
|
||||
\begin{center}
|
||||
\rule{\textwidth}{1pt}\\
|
||||
\textbf{End of Rehabilitation Treatment Plan}\\
|
||||
This document contains confidential patient information protected by HIPAA.
|
||||
\end{center}
|
||||
|
||||
\end{document}
|
||||
|
||||
% ========== NOTES FOR USERS ==========
|
||||
%
|
||||
% CUSTOMIZATION:
|
||||
% - Replace all bracketed placeholders with patient-specific information
|
||||
% - Adjust goals based on baseline assessment
|
||||
% - Modify exercises based on patient tolerance and precautions
|
||||
% - Update DME recommendations as needed
|
||||
%
|
||||
% COMPILATION:
|
||||
% pdflatex rehabilitation_treatment_plan.tex
|
||||
|
||||
411
skills/treatment-plans/references/goal_setting_frameworks.md
Normal file
411
skills/treatment-plans/references/goal_setting_frameworks.md
Normal file
@@ -0,0 +1,411 @@
|
||||
# Goal Setting Frameworks for Treatment Plans
|
||||
|
||||
## Overview
|
||||
|
||||
Effective treatment goals are the cornerstone of successful patient care. This reference provides comprehensive guidance on creating SMART goals, patient-centered outcome selection, and shared decision-making processes for treatment planning across all medical specialties.
|
||||
|
||||
## SMART Goals Framework
|
||||
|
||||
### Definition
|
||||
|
||||
**SMART** is a mnemonic for goal criteria that ensure objectives are well-defined and achievable:
|
||||
- **S**pecific
|
||||
- **M**easurable
|
||||
- **A**chievable
|
||||
- **R**elevant
|
||||
- **T**ime-bound
|
||||
|
||||
### 1. Specific
|
||||
|
||||
Goals must be clear, well-defined, and unambiguous.
|
||||
|
||||
**Components of Specificity**:
|
||||
- **What**: Exactly what will be accomplished
|
||||
- **Who**: Who is responsible (patient, provider, both)
|
||||
- **Where**: Context or setting if relevant
|
||||
- **Which**: Specific aspect of health/function addressed
|
||||
|
||||
**Examples**:
|
||||
|
||||
| Poor (Vague) | Good (Specific) |
|
||||
|--------------|-----------------|
|
||||
| "Feel better" | "Reduce depressive symptoms as measured by PHQ-9 score" |
|
||||
| "Improve diabetes" | "Reduce HbA1c from current 8.5% to less than 7%" |
|
||||
| "Get stronger" | "Increase right quadriceps strength from 3/5 to 4/5 on manual muscle testing" |
|
||||
| "Lose weight" | "Reduce body weight by 10 pounds (from 210 to 200 lbs)" |
|
||||
| "Exercise more" | "Walk 30 minutes, 5 days per week" |
|
||||
|
||||
### 2. Measurable
|
||||
|
||||
Goals must include quantifiable metrics or observable criteria to track progress.
|
||||
|
||||
**Types of Measurement**:
|
||||
- **Quantitative**: Numbers, percentages, scores, scales
|
||||
- Lab values: HbA1c, LDL cholesterol, eGFR
|
||||
- Vital signs: BP, heart rate, weight
|
||||
- Scales: Pain (0-10 NRS), PHQ-9, GAD-7, FIM
|
||||
- Functional: Distance walked, ROM degrees, strength grades
|
||||
|
||||
- **Qualitative Observable**: Behaviors that can be observed and verified
|
||||
- "Patient demonstrates proper insulin injection technique"
|
||||
- "Patient ambulates 150 feet with walker independently"
|
||||
- "Patient follows 2-step commands"
|
||||
|
||||
**Examples**:
|
||||
|
||||
| Not Measurable | Measurable |
|
||||
|----------------|------------|
|
||||
| "Better blood pressure" | "Systolic BP <130 mmHg and diastolic BP <80 mmHg" |
|
||||
| "Less pain" | "Pain intensity reduced from 7/10 to ≤4/10 on numeric rating scale" |
|
||||
| "Improved mobility" | "Ambulate 300 feet with front-wheeled walker, supervision level" |
|
||||
| "Take medications regularly" | "Medication adherence >90% as measured by refill rates" |
|
||||
| "Sleep better" | "Sleep 7-8 hours nightly with <2 awakenings per night" |
|
||||
|
||||
### 3. Achievable
|
||||
|
||||
Goals must be realistic given patient's capabilities, resources, and circumstances.
|
||||
|
||||
**Factors to Consider**:
|
||||
- **Patient capabilities**: Physical, cognitive, psychological capacity
|
||||
- **Severity of condition**: Advanced disease may have limited improvement potential
|
||||
- **Treatment efficacy**: What can realistically be achieved with available treatments
|
||||
- **Resources**: Access to care, medications, equipment, support
|
||||
- **Time available**: Adequate time to achieve the goal
|
||||
- **Motivation**: Patient's readiness to change and engagement
|
||||
|
||||
**Setting Achievable Goals**:
|
||||
- Start with baseline assessment
|
||||
- Know expected treatment effects (e.g., metformin reduces HbA1c by 1-1.5%)
|
||||
- Set incremental goals for large changes (lose 5 lbs, then 10 lbs, rather than jump to 50 lbs)
|
||||
- Challenge but don't overwhelm patient
|
||||
- Adjust goals based on progress
|
||||
|
||||
**Examples**:
|
||||
|
||||
| Not Achievable | Achievable |
|
||||
|----------------|------------|
|
||||
| "Marathon ready in 1 month" (sedentary 70-year-old post-MI) | "Walk 1 mile continuously in 3 months" |
|
||||
| "HbA1c from 12% to <6% in 6 weeks" | "HbA1c from 12% to <9% in 3 months, <7% in 6 months" |
|
||||
| "Full knee ROM 0-140° by POD 3" (post-TKA) | "Knee ROM 0-90° by week 2, 0-110° by week 6" |
|
||||
| "Cure chronic pain" | "Reduce pain from 7/10 to 4/10 and improve function by 30%" |
|
||||
|
||||
### 4. Relevant
|
||||
|
||||
Goals must align with patient values, priorities, and overall treatment objectives.
|
||||
|
||||
**Relevance Criteria**:
|
||||
- **Patient-centered**: Matters to the patient, reflects their priorities
|
||||
- **Clinically meaningful**: Achieving goal improves health or quality of life
|
||||
- **Aligned with diagnosis**: Goal addresses the condition being treated
|
||||
- **Appropriate timing**: Right goal for current phase of treatment
|
||||
- **Integrated**: Fits with other treatment goals
|
||||
|
||||
**Assessing Relevance**:
|
||||
- Ask patient: "What's most important to you?" "What do you want to be able to do?"
|
||||
- Ensure goals address functional limitations that matter to patient
|
||||
- Connect clinical metrics to patient-meaningful outcomes (e.g., "HbA1c <7% reduces risk of vision loss")
|
||||
- Avoid provider-driven goals that don't resonate with patient
|
||||
|
||||
**Examples**:
|
||||
|
||||
| Less Relevant | More Relevant |
|
||||
|---------------|---------------|
|
||||
| "Reduce medication count" (when medications controlling symptoms well) | "Simplify regimen to improve adherence" (if missing doses due to complexity) |
|
||||
| "Perfect blood sugars" (patient's priority is energy) | "Improve energy levels through better glucose control" |
|
||||
| "Walk 5 miles" (patient just wants to shop independently) | "Walk through grocery store without assistance" |
|
||||
|
||||
### 5. Time-Bound
|
||||
|
||||
Goals must have specific deadlines or timeframes for achievement.
|
||||
|
||||
**Timeframe Considerations**:
|
||||
- **Short-term goals**: Days to 3 months
|
||||
- **Intermediate goals**: 3-6 months
|
||||
- **Long-term goals**: 6-12 months or longer for chronic conditions
|
||||
- **Reassessment intervals**: Check progress at defined intervals
|
||||
|
||||
**Time Elements to Include**:
|
||||
- Target date or timeframe
|
||||
- Checkpoint dates for progress review
|
||||
- Frequency of actions (e.g., "exercise 30 min, 5x/week")
|
||||
|
||||
**Examples**:
|
||||
|
||||
| Not Time-Bound | Time-Bound |
|
||||
|----------------|------------|
|
||||
| "Eventually lose weight" | "Lose 15 pounds within 6 months (approximately 1-2 lbs/week)" |
|
||||
| "Attend physical therapy" | "Complete 12 physical therapy sessions over 8 weeks, 1-2x weekly" |
|
||||
| "When ready, return to work" | "Return to modified duty work within 12 weeks post-surgery" |
|
||||
| "Improve depression symptoms" | "Reduce PHQ-9 score from 18 to <10 within 8 weeks of starting SSRI and CBT" |
|
||||
|
||||
## Creating SMART Goals: Step-by-Step Process
|
||||
|
||||
### Step 1: Assess Baseline
|
||||
- Identify current status: symptoms, lab values, functional level
|
||||
- Use standardized assessments when available
|
||||
- Document quantitative baseline
|
||||
|
||||
### Step 2: Identify Desired Outcome
|
||||
- What needs to improve?
|
||||
- Engage patient: "What would you like to be different?"
|
||||
- Consider clinical needs and patient priorities
|
||||
|
||||
### Step 3: Make It Specific
|
||||
- Define exact outcome
|
||||
- Eliminate vague language
|
||||
- Include all relevant details
|
||||
|
||||
### Step 4: Add Measurement
|
||||
- How will progress be tracked?
|
||||
- What metric or observable behavior?
|
||||
- Baseline → Target value
|
||||
|
||||
### Step 5: Reality Check (Achievable?)
|
||||
- Is this possible given patient's condition, resources, treatment effects?
|
||||
- May need to adjust expectations
|
||||
- Set incremental goals if needed
|
||||
|
||||
### Step 6: Ensure Relevance
|
||||
- Does patient care about this goal?
|
||||
- Is it clinically meaningful?
|
||||
- Does it align with overall treatment plan?
|
||||
|
||||
### Step 7: Set Timeline
|
||||
- When will goal be achieved?
|
||||
- When will progress be reviewed?
|
||||
- Break into short-term and long-term if needed
|
||||
|
||||
### Step 8: Document and Communicate
|
||||
- Write goal in clear SMART format
|
||||
- Share with patient and care team
|
||||
- Ensure patient understanding
|
||||
|
||||
## Goal Hierarchies and Levels
|
||||
|
||||
### ICF Framework (International Classification of Functioning, Disability and Health)
|
||||
|
||||
Useful for rehabilitation and functional goals:
|
||||
|
||||
1. **Impairment-Level Goals**: Body structure/function
|
||||
- Example: "Increase shoulder flexion ROM from 90° to 140°"
|
||||
|
||||
2. **Activity-Level Goals**: Task performance
|
||||
- Example: "Dress upper body independently"
|
||||
|
||||
3. **Participation-Level Goals**: Life role engagement
|
||||
- Example: "Return to work as teacher"
|
||||
|
||||
### Medical Outcome Levels
|
||||
|
||||
1. **Biological/Clinical Goals**: Lab values, vital signs, disease markers
|
||||
- Example: "HbA1c <7%, BP <130/80, LDL <70 mg/dL"
|
||||
|
||||
2. **Symptom Goals**: Patient-reported symptoms
|
||||
- Example: "Pain ≤4/10, no dyspnea with ADLs"
|
||||
|
||||
3. **Functional Goals**: What patient can do
|
||||
- Example: "Walk 1 mile, climb 2 flights of stairs"
|
||||
|
||||
4. **Quality of Life Goals**: Overall well-being
|
||||
- Example: "Return to hobbies, improve sleep quality"
|
||||
|
||||
## Patient-Centered Outcome Measures (PCOMs)
|
||||
|
||||
### Definition
|
||||
Outcomes that matter most to patients, beyond traditional clinical metrics.
|
||||
|
||||
### Common PCOMs
|
||||
|
||||
**Patient-Reported Outcome Measures (PROMs)**:
|
||||
- SF-36 or SF-12 (general health-related quality of life)
|
||||
- PROMIS (Patient-Reported Outcomes Measurement Information System)
|
||||
- Disease-specific QoL scales (e.g., Kansas City Cardiomyopathy Questionnaire for HF)
|
||||
|
||||
**Functional Outcomes**:
|
||||
- Activities of Daily Living (ADLs): Bathing, dressing, toileting, transferring, feeding, continence
|
||||
- Instrumental ADLs (IADLs): Shopping, cooking, housekeeping, managing finances, transportation
|
||||
- Occupational/educational functioning
|
||||
- Social functioning and relationships
|
||||
- Recreation and leisure participation
|
||||
|
||||
**Patient Priorities**:
|
||||
- What matters most to individual patient
|
||||
- May differ from clinician priorities
|
||||
- Examples: "Play with grandchildren," "Travel to daughter's wedding," "Avoid nursing home"
|
||||
|
||||
### Integrating PCOMs into Goals
|
||||
|
||||
**Approach**:
|
||||
1. Ask patient about priorities early in assessment
|
||||
2. Link clinical goals to patient-meaningful outcomes
|
||||
3. Include at least some goals directly addressing patient priorities
|
||||
4. Use patient's language in documenting goals when possible
|
||||
|
||||
**Example Integration**:
|
||||
- **Clinical goal**: "Reduce HbA1c from 8.5% to <7% in 3 months"
|
||||
- **Linked patient-centered goal**: "Improve energy levels to play with grandchildren without fatigue"
|
||||
- Both goals documented, progress on both tracked
|
||||
|
||||
## Shared Decision-Making in Goal Setting
|
||||
|
||||
### What is Shared Decision-Making (SDM)?
|
||||
|
||||
Collaborative process where clinicians and patients jointly:
|
||||
- Discuss treatment options
|
||||
- Weigh risks and benefits
|
||||
- Consider patient values and preferences
|
||||
- Make decisions together
|
||||
|
||||
### SDM in Treatment Goal Setting
|
||||
|
||||
**Steps**:
|
||||
|
||||
1. **Choice Awareness**: Acknowledge multiple possible goals/approaches
|
||||
- "We could focus on aggressive HbA1c lowering vs. minimizing hypoglycemia risk. What's more important to you?"
|
||||
|
||||
2. **Option Presentation**: Present goal options with pros/cons
|
||||
- "Option A: Intensive BP control (<120/80) reduces stroke risk but requires more medications. Option B: Standard control (<140/90) is easier but slightly higher stroke risk."
|
||||
|
||||
3. **Values Clarification**: Understand patient priorities
|
||||
- "How do you feel about taking multiple medications?" "How much does avoiding injections matter to you?"
|
||||
|
||||
4. **Preference Integration**: Incorporate preferences into goals
|
||||
- If patient prioritizes avoiding medications → "Control BP with lifestyle changes and one medication if possible"
|
||||
|
||||
5. **Decision**: Agree on goals together
|
||||
- "It sounds like you'd like to try intensive lifestyle changes for 3 months before adding another medication. Let's plan for that."
|
||||
|
||||
6. **Document**: Record shared decision-making process
|
||||
- "Goals established through shared decision-making. Patient expressed preference for..."
|
||||
|
||||
### Decision Aids
|
||||
|
||||
Tools to facilitate SDM:
|
||||
- Option grids comparing approaches
|
||||
- Numerical risk/benefit data
|
||||
- Patient stories/testimonials
|
||||
- Visual aids (pictures, diagrams)
|
||||
- "What matters to you" worksheets
|
||||
|
||||
## Special Considerations for Different Populations
|
||||
|
||||
### Older Adults
|
||||
- Functional independence often priority over disease-specific metrics
|
||||
- Balance aggressive treatment vs. treatment burden
|
||||
- Consider life expectancy and time to benefit
|
||||
- Fall prevention, polypharmacy reduction may be key goals
|
||||
- Quality over quantity of life
|
||||
|
||||
### Pediatric
|
||||
- Developmental stage-appropriate goals
|
||||
- Family-centered (involve parents/caregivers)
|
||||
- Growth and development milestones
|
||||
- School/social functioning
|
||||
- Transition planning (pediatric to adult care)
|
||||
|
||||
### Chronic Disease
|
||||
- Long-term sustainable goals
|
||||
- Balance ambition with realistic expectations
|
||||
- Complication prevention
|
||||
- Quality of life maintenance
|
||||
- Adaptation and acceptance alongside improvement
|
||||
|
||||
### Palliative/End-of-Life
|
||||
- Comfort and symptom management primary
|
||||
- Functional goals focused on valued activities
|
||||
- Psychosocial and spiritual needs
|
||||
- Caregiver support
|
||||
- Dignity and autonomy
|
||||
|
||||
### Complex Multi-Morbidity
|
||||
- Prioritize most impactful goals
|
||||
- Coordinate goals across conditions (when treatments overlap, even better)
|
||||
- Avoid conflicting treatments
|
||||
- Minimize treatment burden
|
||||
- Realistic expectations with multiple conditions
|
||||
|
||||
## Common Goal-Setting Pitfalls
|
||||
|
||||
### Pitfall 1: Provider-Centric Goals
|
||||
**Problem**: Goals reflect what provider thinks is important, not patient priorities
|
||||
**Solution**: Ask patient early in visit what they hope to achieve, incorporate their language
|
||||
|
||||
### Pitfall 2: Too Many Goals
|
||||
**Problem**: Overwhelming patient with 10+ goals
|
||||
**Solution**: Prioritize 3-5 key goals, build on success
|
||||
|
||||
### Pitfall 3: All-or-Nothing Thinking
|
||||
**Problem**: Goal is "cure" or "perfection"
|
||||
**Solution**: Incremental goals, meaningful improvement valued
|
||||
|
||||
### Pitfall 4: Ignoring Barriers
|
||||
**Problem**: Goals set without assessing feasibility (resources, support, access)
|
||||
**Solution**: Identify barriers during assessment, problem-solve or adjust goals
|
||||
|
||||
### Pitfall 5: Static Goals
|
||||
**Problem**: Set goals and never revisit
|
||||
**Solution**: Regular reassessment, modify as patient progresses or circumstances change
|
||||
|
||||
### Pitfall 6: Purely Clinical Metrics
|
||||
**Problem**: All goals are lab values, no functional or QoL goals
|
||||
**Solution**: Balance clinical markers with functional, symptom, and QoL outcomes
|
||||
|
||||
### Pitfall 7: No Patient Buy-In
|
||||
**Problem**: Patient doesn't believe goal is achievable or important
|
||||
**Solution**: Shared decision-making, motivational interviewing to explore ambivalence
|
||||
|
||||
## Examples of SMART Goals by Condition
|
||||
|
||||
### Diabetes
|
||||
**Short-term**: "Reduce HbA1c from 8.5% to <7.5% within 3 months by initiating metformin 1000mg BID and reducing carbohydrate intake to 45-60g per meal."
|
||||
|
||||
**Long-term**: "Maintain HbA1c <7% for 6+ months, prevent microvascular complications, and improve energy levels to engage in daily walking for 30 minutes."
|
||||
|
||||
### Heart Failure
|
||||
**Short-term**: "Achieve euvolemia (no edema, stable weight within 2 lbs) within 2 weeks through furosemide dose optimization and sodium restriction <2000mg/day."
|
||||
|
||||
**Long-term**: "Maintain NYHA Class II functional status, prevent HF hospitalizations, and walk 1/4 mile without dyspnea within 3 months."
|
||||
|
||||
### Depression
|
||||
**Short-term**: "Reduce PHQ-9 score from 18 to <10 within 8 weeks by starting escitalopram 10mg daily and attending weekly CBT sessions."
|
||||
|
||||
**Long-term**: "Achieve depression remission (PHQ-9 <5), return to work full-time, and re-engage in social activities with friends 2-3x/week within 4 months."
|
||||
|
||||
### Post-Stroke Rehabilitation
|
||||
**Short-term**: "Increase right arm strength from 2/5 to 3+/5 and improve Functional Independence Measure (FIM) score from 85 to 100 within 4 weeks through PT/OT 5x/week."
|
||||
|
||||
**Long-term**: "Achieve independence in all ADLs, ambulate 500 feet with cane on level surfaces, and return home (not nursing facility) within 3 months."
|
||||
|
||||
### Chronic Low Back Pain
|
||||
**Short-term**: "Reduce pain intensity from 7/10 to 4/10 and increase walking tolerance from 10 minutes to 30 minutes within 6 weeks using multimodal analgesia (SNRI, NSAID, PT)."
|
||||
|
||||
**Long-term**: "Return to modified duty work within 3 months, engage in hobbies (fishing, gardening with adaptations), and reduce pain interference on daily life by 50% (Brief Pain Inventory)."
|
||||
|
||||
### Hypertension
|
||||
**Short-term**: "Reduce blood pressure from 152/94 to <140/90 mmHg within 4 weeks by initiating lisinopril 10mg daily and reducing sodium intake to <2300mg/day."
|
||||
|
||||
**Long-term**: "Achieve and maintain BP <130/80 mmHg, reduce ASCVD 10-year risk from 15% to <10%, and prevent cardiovascular events."
|
||||
|
||||
## Tools and Resources
|
||||
|
||||
### Goal-Setting Templates
|
||||
- SMART goal worksheet (fill-in-the-blank format)
|
||||
- Goal-tracking sheets for patients
|
||||
- Motivational interviewing "change talk" to elicit goals
|
||||
|
||||
### Assessment Tools
|
||||
- Goal Attainment Scaling (GAS): Personalized outcome measure
|
||||
- Canadian Occupational Performance Measure (COPM): Patient-identified functional goals
|
||||
- Patient-Reported Outcomes Measurement Information System (PROMIS)
|
||||
|
||||
### Patient Education
|
||||
- "Setting Health Goals" handouts
|
||||
- Goal visualization exercises
|
||||
- Tracking apps and logs
|
||||
|
||||
---
|
||||
|
||||
**Document Version**: 1.0
|
||||
**Last Updated**: January 2025
|
||||
**Next Review**: January 2026
|
||||
|
||||
507
skills/treatment-plans/references/intervention_guidelines.md
Normal file
507
skills/treatment-plans/references/intervention_guidelines.md
Normal file
@@ -0,0 +1,507 @@
|
||||
# Evidence-Based Intervention Guidelines
|
||||
|
||||
## Overview
|
||||
|
||||
This reference provides comprehensive guidance on selecting, implementing, and documenting evidence-based interventions across pharmacological, non-pharmacological, and procedural treatment modalities. These guidelines support treatment plan development with current best practices and clinical recommendations.
|
||||
|
||||
## Evidence Hierarchy
|
||||
|
||||
### Levels of Evidence
|
||||
|
||||
**Level I: Highest Quality**
|
||||
- Systematic reviews and meta-analyses of randomized controlled trials (RCTs)
|
||||
- Large multi-center RCTs
|
||||
|
||||
**Level II: High Quality**
|
||||
- Individual RCTs
|
||||
- Systematic reviews of observational studies
|
||||
|
||||
**Level III: Moderate Quality**
|
||||
- Cohort studies
|
||||
- Case-control studies
|
||||
- Well-designed observational studies
|
||||
|
||||
**Level IV: Lower Quality**
|
||||
- Case series
|
||||
- Case reports
|
||||
- Expert opinion
|
||||
|
||||
**Recommendation Strength**:
|
||||
- **Grade A**: Strong recommendation, high-quality evidence
|
||||
- **Grade B**: Moderate recommendation, moderate-quality evidence
|
||||
- **Grade C**: Weak recommendation, low-quality evidence
|
||||
- **Grade D**: Recommendation against (evidence of harm or no benefit)
|
||||
|
||||
## Pharmacological Interventions
|
||||
|
||||
### Medication Selection Principles
|
||||
|
||||
#### 1. Evidence-Based Prescribing
|
||||
- Use medications with proven efficacy for indication
|
||||
- Follow clinical practice guidelines
|
||||
- Consider comparative effectiveness data
|
||||
- Prefer medications with better safety profiles when equivalent efficacy
|
||||
|
||||
#### 2. Patient-Specific Factors
|
||||
- Comorbidities and contraindications
|
||||
- Organ function (renal, hepatic)
|
||||
- Drug allergies and intolerances
|
||||
- Concurrent medications (drug interactions)
|
||||
- Age, pregnancy status
|
||||
- Genetic factors (pharmacogenomics when available)
|
||||
- Cost and insurance coverage
|
||||
|
||||
#### 3. Medication Safety
|
||||
- Start low, go slow (especially in elderly, multiple comorbidities)
|
||||
- Titrate to target dose based on response and tolerance
|
||||
- Monitor for adverse effects
|
||||
- Avoid potentially inappropriate medications (Beers Criteria for elderly)
|
||||
- Polypharmacy reduction when possible
|
||||
|
||||
### Common Medication Classes by Indication
|
||||
|
||||
#### Hypertension
|
||||
|
||||
**First-Line Agents** (per JNC-8, ACC/AHA guidelines):
|
||||
- **ACE Inhibitors** (lisinopril, enalapril): Preferred if diabetes, CKD, or heart failure
|
||||
- **ARBs** (losartan, valsartan): Alternative to ACE if intolerant
|
||||
- **Calcium Channel Blockers** (amlodipine): Particularly effective in elderly, Black patients
|
||||
- **Thiazide Diuretics** (chlorthalidone, HCTZ): Cost-effective, good CV outcomes
|
||||
|
||||
**Dosing Strategy**:
|
||||
- Start single agent at low dose
|
||||
- Titrate to maximum tolerated dose before adding second agent
|
||||
- Combination therapy often needed (2-3 agents)
|
||||
- Monitor BP response, adjust every 2-4 weeks
|
||||
|
||||
#### Type 2 Diabetes Mellitus
|
||||
|
||||
**First-Line** (ADA Standards of Care):
|
||||
- **Metformin**: First-line for all patients unless contraindicated (eGFR <30)
|
||||
- Start 500-850mg daily or BID, titrate to 2000mg total daily
|
||||
|
||||
**Second-Line** (individualize based on comorbidities):
|
||||
- **SGLT2 Inhibitors** (empagliflozin, dapagliflozin): If heart failure or CKD (strong cardio-renal benefits)
|
||||
- **GLP-1 Receptor Agonists** (semaglutide, dulaglutide): If ASCVD or high risk, weight loss needed
|
||||
- **DPP-4 Inhibitors** (sitagliptin): If low hypoglycemia risk desired
|
||||
- **Sulfonylureas** (glipizide): Cost-effective but hypoglycemia risk
|
||||
- **Insulin**: If HbA1c very elevated ($>$10%) or symptoms of hyperglycemia
|
||||
|
||||
#### Depression
|
||||
|
||||
**First-Line SSRIs** (APA guidelines):
|
||||
- Sertraline, escitalopram, fluoxetine, citalopram, paroxetine
|
||||
- Start low (e.g., sertraline 50mg, escitalopram 10mg)
|
||||
- Titrate after 2-4 weeks if partial response
|
||||
- Full trial: 6-8 weeks at therapeutic dose
|
||||
- Continue 6-12 months after remission (longer if recurrent)
|
||||
|
||||
**Second-Line**:
|
||||
- **SNRIs** (venlafaxine, duloxetine): Especially if chronic pain comorbidity
|
||||
- **Bupropion**: If sexual dysfunction concern, smoking cessation
|
||||
- **Mirtazapine**: If insomnia/appetite stimulation needed
|
||||
|
||||
**Augmentation** (if partial response):
|
||||
- Second antidepressant from different class
|
||||
- Atypical antipsychotic (aripiprazole, quetiapine) - FDA-approved augmentation
|
||||
- Lithium, thyroid hormone (triiodothyronine)
|
||||
|
||||
#### Chronic Pain
|
||||
|
||||
**Multimodal Analgesia** (WHO Pain Ladder, CDC Opioid Guidelines):
|
||||
|
||||
**Non-Opioid Analgesics**:
|
||||
- **Acetaminophen**: 3-4g/day divided, safe if liver function normal
|
||||
- **NSAIDs**: Ibuprofen, naproxen, meloxicam - short-term or chronic with GI protection
|
||||
- Monitor: Renal function, BP, GI bleeding risk
|
||||
|
||||
**Adjuvant Analgesics for Neuropathic Pain**:
|
||||
- **Gabapentin**: 300mg titrated to 1800-3600mg/day divided TID
|
||||
- **Pregabalin**: 75mg BID titrated to 150-300mg BID (better bioavailability than gabapentin)
|
||||
- **SNRIs** (duloxetine): 60mg daily for diabetic neuropathy, chronic MSK pain
|
||||
- **TCAs** (amitriptyline, nortriptyline): Low-dose (10-75mg QHS) - second-line due to side effects
|
||||
|
||||
**Topical Agents**:
|
||||
- Lidocaine patches 5%, diclofenac gel, capsaicin cream
|
||||
- Local effect, minimal systemic absorption
|
||||
|
||||
**Opioids** (CDC guidelines - use cautiously):
|
||||
- Only after non-opioid multimodal therapies inadequate
|
||||
- Lowest effective dose, short-acting preferred initially
|
||||
- Avoid $>$90 MME/day if possible
|
||||
- UDS, PDMP monitoring, naloxone co-prescription
|
||||
- Reassess frequently, taper if not meeting functional goals
|
||||
|
||||
#### Heart Failure with Reduced Ejection Fraction (HFrEF)
|
||||
|
||||
**Guideline-Directed Medical Therapy (GDMT)** - "Foundational Four":
|
||||
|
||||
1. **ACE Inhibitor or ARB or ARNI**
|
||||
- ACE: Lisinopril 20-40mg daily, enalapril 10-20mg BID
|
||||
- ARNI (Sacubitril/Valsartan): 24/26mg BID → 97/103mg BID (superior to ACE/ARB)
|
||||
- Monitor: BP, renal function, potassium
|
||||
|
||||
2. **Beta-Blocker**
|
||||
- Carvedilol 3.125-6.25mg BID → 25mg BID (target)
|
||||
- Metoprolol succinate 12.5-25mg daily → 200mg daily
|
||||
- Bisoprolol 1.25mg → 10mg daily
|
||||
- Titrate slowly, monitor HR, BP
|
||||
|
||||
3. **Mineralocorticoid Receptor Antagonist (MRA)**
|
||||
- Spironolactone 12.5-25mg daily (up to 50mg)
|
||||
- Eplerenone 25mg daily → 50mg daily
|
||||
- Monitor: Potassium, renal function (risk hyperkalemia)
|
||||
|
||||
4. **SGLT2 Inhibitor**
|
||||
- Dapagliflozin 10mg daily or empagliflozin 10mg daily
|
||||
- Reduces HF hospitalizations and mortality
|
||||
- Also beneficial for diabetes and CKD
|
||||
|
||||
**Additional Therapies**:
|
||||
- Loop diuretic (furosemide) for volume management (not mortality benefit)
|
||||
- Hydralazine-isosorbide dinitrate (if African American or intolerant to ACE/ARB)
|
||||
- Ivabradine (if EF $\leq$35%, HR $>$70 on max beta-blocker)
|
||||
- Digoxin (symptomatic benefit, reduce hospitalizations)
|
||||
|
||||
### Medication Documentation Best Practices
|
||||
|
||||
**Include in Treatment Plan**:
|
||||
- Generic name (brand name optional)
|
||||
- Dose, route, frequency
|
||||
- Indication/rationale
|
||||
- Titration plan if applicable
|
||||
- Expected timeline for benefit
|
||||
- Key side effects to monitor
|
||||
- Drug interactions
|
||||
- When to adjust or discontinue
|
||||
|
||||
**Example**: "Lisinopril 10mg PO daily - ACE inhibitor for hypertension and renal protection in diabetes. Titrate to 20mg in 2-4 weeks if BP not at goal and tolerating (monitor for cough, hyperkalemia). Target BP <130/80."
|
||||
|
||||
## Non-Pharmacological Interventions
|
||||
|
||||
### Lifestyle Modifications
|
||||
|
||||
#### Diet and Nutrition
|
||||
|
||||
**Mediterranean Diet** (Evidence: multiple RCTs, PREDIMED trial):
|
||||
- **Indications**: Cardiovascular disease prevention, diabetes management
|
||||
- **Components**:
|
||||
- High intake: Fruits, vegetables, whole grains, legumes, nuts, olive oil
|
||||
- Moderate: Fish, poultry
|
||||
- Low: Red meat, sweets
|
||||
- **Evidence**: Reduces cardiovascular events by 30%, improves glucose control
|
||||
- **Implementation**: Dietitian referral for medical nutrition therapy
|
||||
|
||||
**DASH Diet** (Dietary Approaches to Stop Hypertension):
|
||||
- **Indication**: Hypertension
|
||||
- **Components**: High fruits/vegetables, low-fat dairy, reduced sodium (<2300mg, ideally <1500mg)
|
||||
- **Evidence**: Reduces SBP by 8-14 mmHg
|
||||
- **Implementation**: DASH eating plan education, sodium tracking
|
||||
|
||||
**Carbohydrate Counting** (for Diabetes):
|
||||
- Consistent carbohydrate intake: 45-60g per meal
|
||||
- Enables insulin dosing adjustment
|
||||
- Prevents glycemic variability
|
||||
- Dietitian teaches carb counting skills
|
||||
|
||||
**Weight Management**:
|
||||
- Caloric deficit: 500-750 kcal/day for 1-2 lb/week weight loss
|
||||
- Behavior change strategies: Self-monitoring, stimulus control, goal-setting
|
||||
- Structured programs (Weight Watchers, MOVE!, etc.) more effective than self-directed
|
||||
- Pharmacotherapy (GLP-1 agonists, orlistat) or bariatric surgery for BMI $\geq$30-35 with comorbidities
|
||||
|
||||
#### Physical Activity and Exercise
|
||||
|
||||
**Aerobic Exercise**:
|
||||
- **Recommendation**: 150 min/week moderate intensity OR 75 min/week vigorous
|
||||
- **Moderate**: Brisk walking, cycling, swimming - can talk but not sing
|
||||
- **Vigorous**: Running, fast cycling - can say few words before pause
|
||||
- **Benefits**: Cardiovascular health, glucose control, weight management, mood
|
||||
- **Implementation**: Start with 10 min sessions, gradually increase
|
||||
|
||||
**Resistance Training**:
|
||||
- **Recommendation**: 2-3 sessions/week, all major muscle groups
|
||||
- **Benefits**: Muscle strength, bone density, metabolic rate, glucose control
|
||||
- **Implementation**: Bodyweight exercises, resistance bands, free weights, machines
|
||||
|
||||
**Balance and Flexibility**:
|
||||
- Important for fall prevention in elderly
|
||||
- Yoga, tai chi
|
||||
- Stretching routines
|
||||
|
||||
**Exercise Prescription**:
|
||||
- FITT principle: **F**requency, **I**ntensity, **T**ime, **T**ype
|
||||
- Individualize based on fitness level, comorbidities, goals
|
||||
- Cardiac clearance if indicated (using ACSM or ACC/AHA guidelines)
|
||||
|
||||
**Example**: "Aerobic exercise: Walk 30 minutes, 5 days/week at moderate intensity (target HR 50-70% max). Resistance training: Upper and lower body exercises 2x/week, 2 sets of 10-12 reps."
|
||||
|
||||
#### Smoking Cessation
|
||||
|
||||
**Evidence**: Strongest intervention for COPD, cardiovascular disease, cancer prevention
|
||||
|
||||
**5 A's Approach**:
|
||||
1. **Ask**: Screen all patients for tobacco use
|
||||
2. **Advise**: Urge all tobacco users to quit
|
||||
3. **Assess**: Willingness to make quit attempt
|
||||
4. **Assist**: Aid in quitting (counseling + medication)
|
||||
5. **Arrange**: Follow-up contact
|
||||
|
||||
**Pharmacotherapy** (doubles quit rates):
|
||||
- **Nicotine Replacement**: Patch, gum, lozenge - OTC, safe
|
||||
- **Varenicline**: Most effective (Chantix), start 1 week before quit date
|
||||
- **Bupropion**: Alternative, also treats depression
|
||||
- **Combination**: NRT + varenicline/bupropion more effective
|
||||
|
||||
**Counseling**:
|
||||
- Quitline: 1-800-QUIT-NOW
|
||||
- Individual or group counseling
|
||||
- Cognitive-behavioral techniques
|
||||
|
||||
**Implementation**: Set quit date within 30 days, prescribe pharmacotherapy + counseling referral, follow up within 1 week of quit date.
|
||||
|
||||
#### Sleep Hygiene
|
||||
|
||||
**Indications**: Insomnia, poor sleep quality
|
||||
|
||||
**Components**:
|
||||
- Consistent sleep-wake schedule (same bedtime/wake time)
|
||||
- Bedroom: Dark, quiet, cool (60-67°F)
|
||||
- Avoid: Caffeine after 2 PM, alcohol, large meals before bed
|
||||
- Screen time: Stop 1 hour before bed
|
||||
- Wind-down routine: Reading, bath, relaxation
|
||||
- Use bed only for sleep (not TV, work)
|
||||
- If can't sleep after 20 min, get up and do quiet activity
|
||||
|
||||
**Evidence**: Effective for chronic insomnia, often combined with CBT for insomnia (CBT-I)
|
||||
|
||||
#### Stress Management
|
||||
|
||||
**Techniques**:
|
||||
- **Mindfulness meditation**: 10-20 min daily, reduces anxiety, depression
|
||||
- **Progressive muscle relaxation**: Systematic tensing and relaxing muscle groups
|
||||
- **Deep breathing**: Diaphragmatic breathing, 4-7-8 technique
|
||||
- **Yoga, tai chi**: Mind-body practices
|
||||
- **Cognitive restructuring**: Challenge stress-inducing thoughts
|
||||
|
||||
**Evidence**: Reduces stress hormones, improves mood, pain perception
|
||||
|
||||
### Behavioral Interventions
|
||||
|
||||
#### Cognitive Behavioral Therapy (CBT)
|
||||
|
||||
**Indications**: Depression, anxiety, insomnia, chronic pain, substance use
|
||||
|
||||
**Core Components**:
|
||||
- Psychoeducation
|
||||
- Cognitive restructuring (identify and challenge distorted thoughts)
|
||||
- Behavioral activation (increase rewarding activities)
|
||||
- Problem-solving skills
|
||||
- Relapse prevention
|
||||
|
||||
**Evidence**: Equivalent to antidepressants for mild-moderate depression, first-line for anxiety, insomnia
|
||||
|
||||
**Implementation**: 12-16 weekly 50-min sessions with trained therapist, homework between sessions
|
||||
|
||||
**Variants**:
|
||||
- **CBT-I** (insomnia): Sleep restriction, stimulus control, cognitive therapy for sleep
|
||||
- **CBT-CP** (chronic pain): Pain education, activity pacing, cognitive restructuring of pain catastrophizing
|
||||
|
||||
#### Motivational Interviewing (MI)
|
||||
|
||||
**Indication**: Ambivalence about behavior change (diet, exercise, substance use, medication adherence)
|
||||
|
||||
**Principles**:
|
||||
- Express empathy
|
||||
- Develop discrepancy (between current behavior and goals/values)
|
||||
- Roll with resistance (don't argue)
|
||||
- Support self-efficacy
|
||||
|
||||
**Techniques**:
|
||||
- Open-ended questions
|
||||
- Affirmations
|
||||
- Reflective listening
|
||||
- Summarizing
|
||||
- Elicit "change talk"
|
||||
|
||||
**Evidence**: Effective for initiating behavior change in multiple domains
|
||||
|
||||
### Patient Education and Self-Management
|
||||
|
||||
**Components**:
|
||||
- Disease education (pathophysiology, natural history, treatment)
|
||||
- Self-monitoring skills (blood glucose, BP, weight, symptoms)
|
||||
- Medication management (purpose, dosing, side effects)
|
||||
- Symptom recognition and action plans
|
||||
- Lifestyle modification skills
|
||||
- Problem-solving
|
||||
- When to seek care
|
||||
|
||||
**Evidence**: Self-management education improves outcomes in diabetes, asthma, heart failure, chronic pain
|
||||
|
||||
**Delivery**:
|
||||
- Individual education by clinician or educator
|
||||
- Structured programs (DSMES for diabetes, cardiac rehab for heart disease)
|
||||
- Group classes
|
||||
- Written materials, videos, apps
|
||||
|
||||
## Procedural and Interventional Therapies
|
||||
|
||||
### Rehabilitation Therapies
|
||||
|
||||
#### Physical Therapy
|
||||
|
||||
**Indications**: Musculoskeletal injuries, post-surgical rehabilitation, balance/gait disorders, chronic pain
|
||||
|
||||
**Interventions**:
|
||||
- Therapeutic exercise: Strengthening, stretching, endurance
|
||||
- Manual therapy: Soft tissue mobilization, joint mobilization
|
||||
- Gait and balance training
|
||||
- Modalities: Heat, ice, ultrasound, electrical stimulation, TENS
|
||||
- Functional training: ADL retraining, body mechanics
|
||||
|
||||
**Evidence**: Strong evidence for specific conditions (e.g., PT for knee OA reduces pain and improves function equivalent to NSAIDs)
|
||||
|
||||
**Prescription**: Frequency (e.g., 2-3x/week), duration (e.g., 4-8 weeks), specific interventions/goals
|
||||
|
||||
#### Occupational Therapy
|
||||
|
||||
**Indications**: ADL limitations, upper extremity dysfunction, cognitive-perceptual deficits, work-related injuries
|
||||
|
||||
**Interventions**:
|
||||
- ADL/IADL training
|
||||
- Adaptive equipment and environmental modifications
|
||||
- Upper extremity strengthening and coordination
|
||||
- Energy conservation techniques
|
||||
- Cognitive rehabilitation
|
||||
- Work hardening/conditioning
|
||||
|
||||
**Evidence**: Improves independence post-stroke, post-injury, with chronic conditions
|
||||
|
||||
#### Speech-Language Pathology
|
||||
|
||||
**Indications**: Dysphagia, aphasia, dysarthria, cognitive-communication disorders
|
||||
|
||||
**Interventions**:
|
||||
- Swallow therapy and diet modifications
|
||||
- Language therapy (aphasia)
|
||||
- Articulation therapy
|
||||
- Cognitive-linguistic therapy
|
||||
- Augmentative and alternative communication (AAC)
|
||||
|
||||
### Interventional Pain Procedures
|
||||
|
||||
#### Epidural Steroid Injections (ESI)
|
||||
|
||||
**Indication**: Radicular pain from disc herniation or spinal stenosis
|
||||
|
||||
**Evidence**: Moderate-quality evidence for short-term pain relief (3-6 weeks to 3 months), variable long-term benefit
|
||||
|
||||
**Approach**: Fluoroscopy-guided, transforaminal, interlaminar, or caudal
|
||||
|
||||
**Frequency**: Up to 3-4 injections per year
|
||||
|
||||
**Risks**: Infection, bleeding, nerve injury (rare), dural puncture
|
||||
|
||||
#### Radiofrequency Ablation (RFA)
|
||||
|
||||
**Indication**: Facet joint-mediated pain (after positive diagnostic medial branch blocks)
|
||||
|
||||
**Evidence**: Good evidence for lumbar facet pain relief for 6-12 months
|
||||
|
||||
**Procedure**: Thermal lesioning of medial branch nerves supplying facet joints
|
||||
|
||||
**Repeatable**: Can repeat when pain returns
|
||||
|
||||
#### Spinal Cord Stimulation (SCS)
|
||||
|
||||
**Indication**: Refractory chronic neuropathic pain (failed back surgery syndrome, CRPS, diabetic neuropathy)
|
||||
|
||||
**Evidence**: 50-60% achieve $\geq$50% pain relief, improves function
|
||||
|
||||
**Procedure**: Trial lead placement (5-7 days), if successful → permanent implant
|
||||
|
||||
**Technologies**: Traditional, high-frequency, burst stimulation, dorsal root ganglion (DRG)
|
||||
|
||||
### Surgical Interventions
|
||||
|
||||
**When to Refer for Surgery**:
|
||||
- Failed conservative management (adequate trial - typically 6-12 weeks minimum)
|
||||
- Progressive neurologic deficit
|
||||
- Cauda equina syndrome (emergency)
|
||||
- Severe functional limitation affecting quality of life
|
||||
- Structural pathology amenable to surgical correction
|
||||
- Patient preference after risks/benefits discussion
|
||||
|
||||
**Shared Decision-Making**: Discuss operative vs. non-operative management, risks, benefits, expected outcomes, recovery
|
||||
|
||||
## Integrative and Complementary Therapies
|
||||
|
||||
### Acupuncture
|
||||
|
||||
**Evidence**:
|
||||
- **Moderate evidence** for chronic low back pain, osteoarthritis knee pain, tension headaches, migraine
|
||||
- **Mechanism**: Unclear (endorphin release, gate control theory, placebo)
|
||||
|
||||
**Implementation**: 8-12 sessions by licensed acupuncturist
|
||||
|
||||
### Massage Therapy
|
||||
|
||||
**Evidence**: Modest benefit for chronic low back pain, anxiety, cancer-related symptoms
|
||||
|
||||
**Types**: Swedish, deep tissue, myofascial release
|
||||
|
||||
**Implementation**: 1-2x/week, 30-60 min sessions
|
||||
|
||||
### Yoga
|
||||
|
||||
**Evidence**: Improves back pain, balance, flexibility, reduces stress and anxiety
|
||||
|
||||
**Types**: Hatha (gentle), Vinyasa (flowing), Iyengar (alignment-focused)
|
||||
|
||||
**Implementation**: Group classes or home practice, 2-3x/week
|
||||
|
||||
### Mindfulness-Based Stress Reduction (MBSR)
|
||||
|
||||
**Evidence**: Reduces stress, anxiety, depression, chronic pain
|
||||
|
||||
**Program**: 8-week structured program, weekly 2.5-hour sessions, daily home practice
|
||||
|
||||
**Components**: Meditation, body scan, mindful movement (yoga)
|
||||
|
||||
### Chiropractic Care
|
||||
|
||||
**Evidence**: Effective for acute and chronic low back pain, neck pain
|
||||
|
||||
**Techniques**: Spinal manipulation, mobilization, soft tissue therapy
|
||||
|
||||
**Safety**: Generally safe, avoid high-velocity manipulation if osteoporosis, spinal instability
|
||||
|
||||
## Intervention Selection and Documentation
|
||||
|
||||
### Treatment Algorithm Approach
|
||||
|
||||
1. **Diagnosis-Specific**: Follow evidence-based guidelines for condition
|
||||
2. **Severity-Appropriate**: Mild → conservative; severe → aggressive
|
||||
3. **Stepwise Intensification**: Start with first-line, add or switch if inadequate response
|
||||
4. **Multimodal**: Combine complementary interventions (pharmacologic + non-pharmacologic)
|
||||
5. **Individualized**: Adjust for patient factors (comorbidities, preferences, resources)
|
||||
|
||||
### Documentation Template
|
||||
|
||||
For each intervention, document:
|
||||
- **Intervention**: Specific name/type
|
||||
- **Indication**: Why this intervention for this patient
|
||||
- **Evidence**: Guideline-based, RCT data supporting use
|
||||
- **Dose/Frequency/Duration**: Specific parameters
|
||||
- **Expected Benefit**: What should improve, by how much, when
|
||||
- **Monitoring**: How will response be assessed
|
||||
- **Risks/Side Effects**: Key concerns to monitor
|
||||
- **Alternatives Considered**: What else was considered, why not chosen
|
||||
|
||||
---
|
||||
|
||||
**Document Version**: 1.0
|
||||
**Last Updated**: January 2025
|
||||
**Next Review**: January 2026
|
||||
|
||||
476
skills/treatment-plans/references/regulatory_compliance.md
Normal file
476
skills/treatment-plans/references/regulatory_compliance.md
Normal file
@@ -0,0 +1,476 @@
|
||||
# Regulatory Compliance for Treatment Plans
|
||||
|
||||
## Overview
|
||||
|
||||
Treatment plans must comply with multiple federal and state regulations governing healthcare documentation, patient privacy, billing practices, and quality standards. This reference provides comprehensive guidance on regulatory requirements affecting treatment plan development and implementation.
|
||||
|
||||
## HIPAA Privacy and Security
|
||||
|
||||
### Health Insurance Portability and Accountability Act (HIPAA)
|
||||
|
||||
**Applicable Rules**:
|
||||
- Privacy Rule (45 CFR Part 164, Subpart E)
|
||||
- Security Rule (45 CFR Part 164, Subparts A and C)
|
||||
- Breach Notification Rule (45 CFR Part 164, Subpart D)
|
||||
|
||||
### Protected Health Information (PHI)
|
||||
|
||||
**Definition**: Any information about health status, provision of healthcare, or payment for healthcare that can be linked to a specific individual.
|
||||
|
||||
**18 HIPAA Identifiers** (Safe Harbor Method):
|
||||
1. Names
|
||||
2. Geographic subdivisions smaller than state (street address, city, county, ZIP code if <20,000 people)
|
||||
3. Dates (birth, admission, discharge, death) - except year
|
||||
4. Telephone numbers
|
||||
5. Fax numbers
|
||||
6. Email addresses
|
||||
7. Social Security numbers
|
||||
8. Medical record numbers
|
||||
9. Health plan beneficiary numbers
|
||||
10. Account numbers
|
||||
11. Certificate/license numbers
|
||||
12. Vehicle identifiers and serial numbers (license plate)
|
||||
13. Device identifiers and serial numbers
|
||||
14. Web URLs
|
||||
15. IP addresses
|
||||
16. Biometric identifiers (fingerprints, voice prints)
|
||||
17. Full-face photographs
|
||||
18. Any other unique identifying number, characteristic, or code
|
||||
|
||||
### De-identification for Sharing Treatment Plans
|
||||
|
||||
**Safe Harbor Method**: Remove all 18 identifiers listed above
|
||||
|
||||
**Practical De-identification**:
|
||||
- **Name**: Use "Patient" or de-identified code (e.g., "PT-001")
|
||||
- **Age**: Use age range (e.g., "60-65 years") instead of exact age
|
||||
- **Dates**: Use relative timelines (e.g., "3 months ago") or month/year only
|
||||
- **Location**: State only, remove city, address, specific facility names
|
||||
- **Identifiers**: Remove MRN, account numbers, SSN
|
||||
- **Dates of Service**: Refer to "Month/Year" or "recent visit"
|
||||
|
||||
**Example**:
|
||||
- **Before**: "John Smith, DOB 3/15/1965 (58 years old), MRN 123456, address 123 Main St, Anytown, CA 12345, seen 1/15/2025"
|
||||
- **After**: "Patient, age range 55-60 years, seen Month/Year 2025, California"
|
||||
|
||||
### Permitted Uses and Disclosures
|
||||
|
||||
**Without Patient Authorization**:
|
||||
- **Treatment**: Sharing PHI among healthcare providers for patient care
|
||||
- **Payment**: Disclosing PHI to obtain payment for services
|
||||
- **Healthcare Operations**: Quality improvement, training, accreditation
|
||||
|
||||
**With Patient Authorization**:
|
||||
- Marketing
|
||||
- Research (unless IRB waiver granted)
|
||||
- Sharing with non-covered entities (e.g., patient's employer)
|
||||
- Psychotherapy notes (special protection)
|
||||
|
||||
### Minimum Necessary Standard
|
||||
|
||||
Use, disclose, or request only the minimum amount of PHI necessary to accomplish the purpose.
|
||||
|
||||
**Exception**: Does NOT apply to treatment - providers may share all relevant information for patient care.
|
||||
|
||||
### Patient Rights Under HIPAA
|
||||
|
||||
- Right to access own medical records (within 30 days)
|
||||
- Right to request amendments to records
|
||||
- Right to accounting of disclosures
|
||||
- Right to request restrictions on uses/disclosures (provider may deny)
|
||||
- Right to confidential communications
|
||||
- Right to be notified of privacy practices (Notice of Privacy Practices)
|
||||
|
||||
### Breach Notification
|
||||
|
||||
**Breach**: Unauthorized acquisition, access, use, or disclosure of PHI that compromises security or privacy.
|
||||
|
||||
**Notification Requirements**:
|
||||
- **Individual**: Notify affected individuals within 60 days
|
||||
- **HHS**: If $\geq$500 individuals affected, notify HHS and media
|
||||
- **Business Associates**: Must notify covered entity of breaches
|
||||
|
||||
### HIPAA Violations and Penalties
|
||||
|
||||
**Civil Penalties**: $100 to $50,000 per violation (up to $1.5 million per year for identical violations)
|
||||
|
||||
**Criminal Penalties**: Up to $250,000 fine and 10 years imprisonment for knowing misuse with intent to sell/transfer PHI
|
||||
|
||||
## 42 CFR Part 2 (Substance Use Disorder Records)
|
||||
|
||||
### Applicability
|
||||
|
||||
**Scope**: Federally assisted substance use disorder (SUD) treatment programs
|
||||
|
||||
**More Restrictive than HIPAA**: Provides additional confidentiality protections for SUD treatment records.
|
||||
|
||||
### Key Requirements
|
||||
|
||||
**Patient Consent Required** for most disclosures (even for treatment, payment, operations - differs from HIPAA).
|
||||
|
||||
**Prohibition on Re-disclosure**: Recipients of 42 CFR Part 2-protected information cannot re-disclose without patient consent.
|
||||
|
||||
**Documentation**: Patient consent must be written, specific to the information disclosed, and include expiration date.
|
||||
|
||||
**Exceptions** (Disclosure without consent allowed):
|
||||
- Medical emergency
|
||||
- Court order (not subpoena alone)
|
||||
- Suspected child abuse/neglect (per state law)
|
||||
- Crime on premises or against personnel
|
||||
|
||||
### Integration with HIPAA
|
||||
|
||||
**HIPAA Compliance**: Covered entities must comply with both HIPAA and 42 CFR Part 2 (whichever is more protective applies).
|
||||
|
||||
**Note in Treatment Plans**: If patient has SUD and received treatment at 42 CFR Part 2 program, annotate: "Substance use information subject to 42 CFR Part 2 confidentiality protections."
|
||||
|
||||
## 21 CFR Part 11 (Electronic Records - FDA)
|
||||
|
||||
### Applicability
|
||||
|
||||
**Scope**: Clinical trials, research involving FDA-regulated products, drug/device manufacturers.
|
||||
|
||||
**Requirements for Electronic Records and Signatures**:
|
||||
- Validation of systems
|
||||
- Audit trails (who accessed, when, what changed)
|
||||
- Electronic signatures equivalent to handwritten
|
||||
- Controls to prevent unauthorized access
|
||||
|
||||
### Treatment Plan Implications
|
||||
|
||||
**If part of clinical trial**: Treatment plans must meet 21 CFR Part 11 requirements for electronic documentation.
|
||||
|
||||
**Non-Research Clinical Care**: Typically NOT subject to 21 CFR Part 11 (HIPAA Security Rule applies instead).
|
||||
|
||||
## Medicare and Medicaid (CMS) Requirements
|
||||
|
||||
### Conditions of Participation (CoPs)
|
||||
|
||||
**Hospitals, Skilled Nursing Facilities, Home Health Agencies** must meet CoPs to receive Medicare/Medicaid reimbursement.
|
||||
|
||||
**Documentation Requirements**:
|
||||
- Physician orders for treatments
|
||||
- Comprehensive care plans
|
||||
- Periodic reassessment and revision
|
||||
- Interdisciplinary team involvement
|
||||
- Patient/family involvement
|
||||
|
||||
### Meaningful Use / Promoting Interoperability
|
||||
|
||||
**EHR Requirements** (for eligible providers to receive incentive payments):
|
||||
- Use of certified EHR technology
|
||||
- Electronic prescribing
|
||||
- Clinical decision support
|
||||
- Patient portal access to health information
|
||||
- Care plan documentation with patient goals
|
||||
|
||||
### Documentation for Billing
|
||||
|
||||
**Medical Necessity**: Documentation must support the medical necessity of services billed.
|
||||
|
||||
**Elements to Document**:
|
||||
- Diagnosis (ICD-10 codes)
|
||||
- Treatments provided (CPT codes)
|
||||
- Rationale for treatments
|
||||
- Patient response to treatment
|
||||
- Plans for ongoing care
|
||||
|
||||
**E/M Coding Support**: Treatment plans support Evaluation and Management (E/M) coding levels:
|
||||
- Low complexity: Stable chronic conditions, limited treatment options
|
||||
- Moderate complexity: Multiple conditions, moderate-risk medications/procedures
|
||||
- High complexity: Severe conditions, high-risk treatments, poor response to therapy
|
||||
|
||||
## Quality Measure Reporting
|
||||
|
||||
### HEDIS (Healthcare Effectiveness Data and Information Set)
|
||||
|
||||
**Used by**: Health plans to measure quality
|
||||
|
||||
**Treatment Plan Elements Supporting HEDIS**:
|
||||
|
||||
**Diabetes**:
|
||||
- HbA1c testing (at least annually, quarterly if not controlled)
|
||||
- Eye exam (annual dilated retinal exam)
|
||||
- Kidney disease monitoring (urine albumin-to-creatinine ratio annually)
|
||||
- BP control (<140/90)
|
||||
|
||||
**Cardiovascular**:
|
||||
- Statin therapy for patients with diabetes or ASCVD
|
||||
- ACE/ARB for patients with diabetes and hypertension
|
||||
- Beta-blocker for patients with prior MI or HFrEF
|
||||
|
||||
**Preventive Care**:
|
||||
- Flu vaccine annually
|
||||
- Colorectal cancer screening
|
||||
- Breast cancer screening
|
||||
- Cervical cancer screening
|
||||
|
||||
### MIPS (Merit-Based Incentive Payment System)
|
||||
|
||||
**Eligible Clinicians**: Medicare Part B providers
|
||||
|
||||
**Performance Categories**:
|
||||
1. **Quality**: Reporting on quality measures relevant to specialty
|
||||
2. **Improvement Activities**: Participation in improvement activities
|
||||
3. **Promoting Interoperability**: EHR meaningful use
|
||||
4. **Cost**: Resource use/cost of care
|
||||
|
||||
**Treatment Plan Documentation**: Supports quality measure reporting (e.g., diabetes HbA1c control, depression screening and follow-up).
|
||||
|
||||
### Accountable Care Organizations (ACOs)
|
||||
|
||||
**Quality Measures**: 33+ measures across patient experience, care coordination, preventive health, at-risk populations.
|
||||
|
||||
**Treatment Plans**: Facilitate care coordination, chronic disease management to meet ACO quality benchmarks.
|
||||
|
||||
## Opioid Prescribing Regulations
|
||||
|
||||
### CDC Opioid Prescribing Guidelines (2022)
|
||||
|
||||
**Recommendations**:
|
||||
- Non-opioid therapies preferred for chronic pain
|
||||
- If opioids used: Lowest effective dose, shortest duration
|
||||
- Assess risk before starting opioids (ORT, SOAPP)
|
||||
- Prescribe naloxone for patients at increased overdose risk
|
||||
- Urine drug testing before and during opioid therapy
|
||||
- Check PDMP (Prescription Drug Monitoring Program) before prescribing
|
||||
- Avoid concurrent benzodiazepines and opioids
|
||||
- Reassess risk/benefit at each increase in dose (especially if approaching $\geq$50 MME/day)
|
||||
|
||||
**Treatment Plan Requirements**:
|
||||
- Document indication for opioid therapy
|
||||
- Informed consent discussion (risks, benefits, alternatives)
|
||||
- Treatment agreement/opioid contract
|
||||
- Plan for monitoring (UDS frequency, PDMP checks)
|
||||
- Functional goals (not just pain scores)
|
||||
- Exit strategy/tapering plan
|
||||
|
||||
### State Opioid Regulations
|
||||
|
||||
**Vary by State**, common elements:
|
||||
- MME limits (e.g., 90 MME/day max without exemption)
|
||||
- Prescription limits for acute pain (e.g., 7-day supply)
|
||||
- Mandatory PDMP checks before prescribing
|
||||
- Continuing medical education (CME) requirements for prescribers
|
||||
- Co-prescription of naloxone required in some states
|
||||
|
||||
**Prescribers must know state-specific laws**.
|
||||
|
||||
### PDMP (Prescription Drug Monitoring Program)
|
||||
|
||||
**Purpose**: State databases tracking controlled substance prescriptions to identify doctor shopping, overprescribing.
|
||||
|
||||
**Requirements**: Most states require PDMP check before initial opioid prescription and periodically during treatment (e.g., every 3-6 months).
|
||||
|
||||
**Documentation**: Note in treatment plan that PDMP was checked and findings (e.g., "PDMP reviewed, no other controlled substances from other prescribers").
|
||||
|
||||
## State Medical Board Requirements
|
||||
|
||||
### Scope of Practice
|
||||
|
||||
**Prescribers**: Must operate within scope of practice defined by state law.
|
||||
- Physicians (MD/DO): Full prescriptive authority
|
||||
- Nurse Practitioners (NP): Varies by state (full practice, reduced practice, or restricted practice authority)
|
||||
- Physician Assistants (PA): Supervision requirements vary
|
||||
|
||||
**Controlled Substances**: DEA registration required, state regulations apply.
|
||||
|
||||
### Standard of Care
|
||||
|
||||
**Definition**: Degree of care and skill ordinarily employed by similar practitioners under similar circumstances.
|
||||
|
||||
**Deviations from Standard**: Must be documented with rationale (e.g., patient-specific factors, shared decision-making, evidence supporting alternative approach).
|
||||
|
||||
### Informed Consent Documentation
|
||||
|
||||
**Required for**: Procedures, surgeries, medications with significant risks, research.
|
||||
|
||||
**Elements to Document**:
|
||||
- Nature of condition and proposed treatment
|
||||
- Risks and benefits
|
||||
- Alternatives
|
||||
- Likely outcome if no treatment
|
||||
- Patient questions answered
|
||||
- Patient capacity to consent
|
||||
- Voluntary consent
|
||||
|
||||
**In Treatment Plans**: Note informed consent discussion occurred, especially for high-risk treatments (e.g., opioids, chemotherapy, surgery).
|
||||
|
||||
### Documentation Retention
|
||||
|
||||
**Medical Records**: State laws vary (typically 7-10 years from last encounter; longer for minors - often until age of majority + statute of limitations).
|
||||
|
||||
**Electronic Records**: Same retention requirements as paper.
|
||||
|
||||
## Accreditation Standards
|
||||
|
||||
### The Joint Commission
|
||||
|
||||
**Applicable to**: Hospitals, ambulatory care, behavioral health, long-term care, laboratories.
|
||||
|
||||
**Standards Relevant to Treatment Plans**:
|
||||
|
||||
**Patient-Centered Care (PC)**:
|
||||
- Individualized care planning
|
||||
- Patient and family involvement
|
||||
- Cultural and language needs addressed
|
||||
- Patient preferences incorporated
|
||||
|
||||
**Care Coordination (CC)**:
|
||||
- Comprehensive assessment
|
||||
- Care plan addresses all identified needs
|
||||
- Interdisciplinary coordination
|
||||
- Transitions of care managed
|
||||
|
||||
**Medication Management (MM)**:
|
||||
- Medication reconciliation at transitions
|
||||
- High-risk medication monitoring (anticoagulants, opioids, insulin)
|
||||
- Patient education on medications
|
||||
|
||||
**National Patient Safety Goals (NPSG)**:
|
||||
- Accurate patient identification
|
||||
- Effective communication among caregivers
|
||||
- Safe medication use
|
||||
- Reduce healthcare-associated infections
|
||||
- Prevent falls
|
||||
|
||||
### CARF (Commission on Accreditation of Rehabilitation Facilities)
|
||||
|
||||
**Applicable to**: Rehabilitation, behavioral health, employment services.
|
||||
|
||||
**Standards for Treatment Plans**:
|
||||
- Comprehensive assessment drives plan
|
||||
- Individualized goals
|
||||
- Measurable, time-specific objectives
|
||||
- Regular team review and updates
|
||||
- Person-centered (patient directs goals)
|
||||
- Transition and discharge planning
|
||||
- Outcomes measurement
|
||||
|
||||
## Billing and Reimbursement Compliance
|
||||
|
||||
### Coding Accuracy
|
||||
|
||||
**ICD-10-CM Diagnosis Codes**:
|
||||
- Code to highest level of specificity
|
||||
- Code all documented conditions affecting care during encounter
|
||||
- Primary diagnosis is reason for visit
|
||||
- Uncertain diagnoses coded as symptoms (outpatient); can code "probable" if inpatient
|
||||
|
||||
**CPT Procedure Codes**:
|
||||
- Specific codes for services provided
|
||||
- Modifiers when appropriate
|
||||
- Unbundling prohibited (billing separately for bundled services)
|
||||
|
||||
### Documentation Supports Billing
|
||||
|
||||
**Medical Necessity**: Treatment must be medically appropriate for diagnosis, meet standard of care, expected to improve condition.
|
||||
|
||||
**Treatment Plan Link**: Plan documents rationale for tests, treatments, referrals → supports medical necessity.
|
||||
|
||||
**Avoid**:
|
||||
- Upcoding (billing higher level service than provided)
|
||||
- Duplicate billing
|
||||
- Billing for services not rendered
|
||||
|
||||
**Anti-Kickback Statute**: Prohibits offering, paying, soliciting, or receiving remuneration for patient referrals for services reimbursed by federal healthcare programs.
|
||||
|
||||
**Stark Law**: Prohibits physician self-referral for designated health services (DHS) covered by Medicare/Medicaid.
|
||||
|
||||
## Clinical Research and Trials
|
||||
|
||||
### Informed Consent (21 CFR Part 50)
|
||||
|
||||
**Required Elements**:
|
||||
- Research procedures described
|
||||
- Risks and discomforts
|
||||
- Potential benefits
|
||||
- Alternative treatments
|
||||
- Confidentiality protections
|
||||
- Voluntary participation, can withdraw
|
||||
- Contact information for questions/problems
|
||||
|
||||
**Documentation**: Signed consent form, copy given to participant.
|
||||
|
||||
### IRB Review (21 CFR Part 56)
|
||||
|
||||
**Institutional Review Board** reviews and approves research involving human subjects.
|
||||
|
||||
**Treatment Plans in Research**: If part of clinical trial protocol, must be approved by IRB, follow protocol exactly, documented per 21 CFR Part 11.
|
||||
|
||||
### Good Clinical Practice (ICH-GCP)
|
||||
|
||||
**International Standard** for ethical and scientific quality in clinical trials.
|
||||
|
||||
**Relevant to Treatment Plans**: Detailed protocol adherence, documentation of interventions, adverse event reporting.
|
||||
|
||||
## Mental Health Specific Regulations
|
||||
|
||||
### Duty to Warn/Protect
|
||||
|
||||
**Tarasoff Rule** (varies by state): If patient poses credible threat to identifiable person, provider must:
|
||||
- Warn intended victim
|
||||
- Notify police
|
||||
- Take steps to protect
|
||||
|
||||
**Documentation**: Document threat assessment, steps taken to protect.
|
||||
|
||||
### Involuntary Commitment
|
||||
|
||||
**Criteria** (vary by state): Typically requires patient to be:
|
||||
- Mentally ill, AND
|
||||
- Danger to self or others OR gravely disabled
|
||||
|
||||
**Due Process**: Emergency hold (24-72 hours), followed by court hearing for longer commitment.
|
||||
|
||||
**Documentation**: Clear documentation of dangerousness, efforts at least restrictive intervention.
|
||||
|
||||
### Parity Laws
|
||||
|
||||
**Mental Health Parity and Addiction Equity Act (MHPAEA)**: Health plans must provide mental health/substance use disorder benefits comparable to medical/surgical benefits.
|
||||
|
||||
**Implications**: Cannot limit therapy visits or impose higher copays for mental health vs. medical care.
|
||||
|
||||
## Compliance Best Practices
|
||||
|
||||
### 1. Know Applicable Regulations
|
||||
- Federal (HIPAA, 42 CFR Part 2, CDC guidelines, CMS CoPs)
|
||||
- State (medical practice act, opioid laws, consent requirements)
|
||||
- Accreditation (Joint Commission, CARF if applicable)
|
||||
|
||||
### 2. Document Thoroughly
|
||||
- Complete all required elements
|
||||
- Clear rationale for clinical decisions
|
||||
- Informed consent discussions
|
||||
- Regulatory compliance (PDMP checks, etc.)
|
||||
|
||||
### 3. Privacy Protection
|
||||
- De-identify before sharing outside treatment team
|
||||
- Minimum necessary principle
|
||||
- Secure storage and transmission of records
|
||||
|
||||
### 4. Quality Measure Integration
|
||||
- Include elements that support quality reporting (preventive care, chronic disease metrics)
|
||||
- Structured data enables measure extraction
|
||||
|
||||
### 5. Regular Training
|
||||
- HIPAA training annually for all staff
|
||||
- Updates on regulation changes
|
||||
- Specialty-specific compliance (opioid prescribing, mental health)
|
||||
|
||||
### 6. Audit and Monitor
|
||||
- Internal audits for documentation compliance
|
||||
- Billing compliance reviews
|
||||
- Privacy breach monitoring
|
||||
|
||||
### 7. Policies and Procedures
|
||||
- Written policies on treatment planning, consent, privacy
|
||||
- Regularly reviewed and updated
|
||||
|
||||
---
|
||||
|
||||
**Document Version**: 1.0
|
||||
**Last Updated**: January 2025
|
||||
**Next Review**: January 2026
|
||||
**Note**: Regulations subject to change; verify current requirements.
|
||||
|
||||
@@ -0,0 +1,655 @@
|
||||
# Specialty-Specific Treatment Plan Guidelines
|
||||
|
||||
## Overview
|
||||
|
||||
This reference provides detailed guidelines for developing treatment plans specific to each of the six template types: general medical, rehabilitation, mental health, chronic disease management, perioperative, and pain management. Each section includes specialty-specific considerations, clinical pearls, and best practices.
|
||||
|
||||
## Concise Documentation Examples by Specialty
|
||||
|
||||
### Foundation Medicine Model: Concise vs. Verbose
|
||||
|
||||
**PRINCIPLE**: Focus on actionable information; eliminate redundancy; use bullet points and short paragraphs.
|
||||
|
||||
### General Medical - Diabetes Example
|
||||
|
||||
**VERBOSE (Avoid)**:
|
||||
> "Patient education was provided on the pathophysiology of Type 2 Diabetes Mellitus, including detailed explanation of insulin resistance, pancreatic beta-cell dysfunction, and the progressive nature of the disease. The patient was educated about the various potential complications of diabetes including microvascular complications such as diabetic retinopathy which can lead to blindness, diabetic nephropathy which can progress to end-stage renal disease requiring dialysis, and diabetic neuropathy which can cause pain and sensory loss. Additionally, macrovascular complications were discussed including increased risk of myocardial infarction, stroke, and peripheral arterial disease."
|
||||
|
||||
**CONCISE (Preferred - 75% shorter)**:
|
||||
> "Key Education: Disease understanding, micro/macrovascular complication risks, self-monitoring techniques (glucose, BP), medication timing, diet basics, exercise safety, sick day management. Critical warnings: Hypoglycemia (shakiness, confusion - treat with 15g carbs), severe hyperglycemia >300 (call office), chest pain/stroke symptoms (911)."
|
||||
|
||||
### Mental Health - Depression Example
|
||||
|
||||
**VERBOSE (Avoid)**:
|
||||
> "The patient will participate in individual psychotherapy sessions utilizing Cognitive Behavioral Therapy techniques. Sessions will be scheduled on a weekly basis for a duration of 50 minutes each. The therapist will work with the patient to identify negative thought patterns, challenge cognitive distortions, develop behavioral activation strategies, and build coping skills for managing depressive symptoms."
|
||||
|
||||
**CONCISE (Preferred - 60% shorter)**:
|
||||
> "CBT weekly × 16 sessions (50 min) focusing on: identifying/challenging negative thoughts, behavioral activation, coping skills development. Goals: PHQ-9 <10, return to work, 3 effective stress management strategies."
|
||||
|
||||
### Rehabilitation - Post-Stroke Example
|
||||
|
||||
**VERBOSE (Avoid)**:
|
||||
> "Expected outcomes include improvement in upper extremity function with anticipated achievement of the ability to perform self-care activities including bathing, dressing, and grooming with minimal assistance or independently. The patient is expected to demonstrate improved ambulation capabilities with progression from wheelchair mobility to ambulation with a rolling walker under supervision, with eventual goal of independent ambulation with a straight cane for distances up to 300 feet."
|
||||
|
||||
**CONCISE (Preferred - 70% shorter)**:
|
||||
> "Expected outcomes (8 weeks): Independent ADLs with adaptive equipment, ambulation 300+ feet with walker/supervision, stair negotiation with handrail, safe home discharge. Timeline: Week 2 - transfers with supervision; Week 4 - ambulate 150 feet; Week 8 - community ambulation, discharge ready."
|
||||
|
||||
### Perioperative - Laparoscopic Surgery Example
|
||||
|
||||
**VERBOSE (Avoid)**:
|
||||
> "Postoperative pain management will utilize a multimodal approach to analgesia in order to minimize opioid consumption and reduce the risk of opioid-related adverse effects including nausea, vomiting, constipation, and respiratory depression. The multimodal regimen will include scheduled acetaminophen administered at a dose of 1000 milligrams every 6 hours, ibuprofen 600 milligrams every 6 hours as needed, and opioid analgesics reserved for breakthrough pain only."
|
||||
|
||||
**CONCISE (Preferred - 65% shorter)**:
|
||||
> "Multimodal analgesia: Acetaminophen 1000mg Q6H scheduled, ibuprofen 600mg Q6H PRN, opioids for breakthrough only. Goal: Pain <4/10, minimize opioid use, early mobilization."
|
||||
|
||||
### Key Principles for Concise Documentation
|
||||
|
||||
1. **Use abbreviations appropriately**: Q6H, PRN, ADLs, BP (define on first use if uncommon)
|
||||
2. **Bullet points over paragraphs**: Easier to scan, more actionable
|
||||
3. **Combine related information**: Group similar items together
|
||||
4. **Eliminate filler words**: "The patient will...", "It is anticipated that..."
|
||||
5. **Focus on "what, when, why"**: Action, timing, rationale in minimal words
|
||||
6. **Use tables for complex data**: Medication lists, monitoring schedules
|
||||
7. **Prioritize critical information**: Safety warnings, emergency actions
|
||||
|
||||
## 1. General Medical Treatment Plans
|
||||
|
||||
### Applicable Conditions
|
||||
- Chronic diseases: Diabetes, hypertension, heart failure, COPD, asthma
|
||||
- Common acute conditions requiring structured follow-up
|
||||
- Primary care management of stable chronic conditions
|
||||
|
||||
### Key Assessment Components
|
||||
|
||||
**Baseline Status**:
|
||||
- Vital signs, BMI, functional status
|
||||
- Disease-specific metrics (HbA1c, BP, lipids, PFTs)
|
||||
- Comorbidity assessment
|
||||
- Medication reconciliation
|
||||
- Social determinants of health screening
|
||||
|
||||
**Disease Severity Staging**:
|
||||
- Use validated staging systems when available
|
||||
- Examples: CKD stages 1-5, GOLD COPD stages I-IV, NYHA heart failure classes I-IV, ADA diabetes complications
|
||||
- Document severity to guide treatment intensity
|
||||
|
||||
### Treatment Goal Specifics
|
||||
|
||||
**Guideline-Based Targets**:
|
||||
- HbA1c <7% for most diabetics (<8% if elderly, limited life expectancy)
|
||||
- BP <130/80 for most; <140/90 if elderly or low cardiovascular risk
|
||||
- LDL <70 mg/dL if ASCVD, <100 mg/dL moderate risk
|
||||
- Use individualized targets based on patient factors
|
||||
|
||||
**Functional Goals**:
|
||||
- Maintain independence in ADLs
|
||||
- Return to work if applicable
|
||||
- Engage in valued activities
|
||||
- Quality of life improvement
|
||||
|
||||
### Pharmacotherapy Considerations
|
||||
|
||||
**Polypharmacy Management**:
|
||||
- Consider deprescribing when possible (Beers Criteria for elderly)
|
||||
- Medication reconciliation at each visit
|
||||
- Simplify regimens (once-daily dosing, combination pills)
|
||||
- Address adherence barriers (cost, side effects, complexity)
|
||||
|
||||
**Drug-Disease Interactions**:
|
||||
- Avoid NSAIDs if CKD, heart failure
|
||||
- Caution with metformin if eGFR <30
|
||||
- Beta-blockers contraindicated in severe COPD/asthma (use cardioselective if needed)
|
||||
|
||||
### Monitoring Schedules by Condition
|
||||
|
||||
**Diabetes**:
|
||||
- HbA1c every 3 months if not at goal, every 6 months if stable
|
||||
- Annual: dilated eye exam, foot exam, urine ACR, lipids
|
||||
- Each visit: BP, weight, medication adherence
|
||||
|
||||
**Hypertension**:
|
||||
- Home BP monitoring (HBPM) - most accurate, average of multiple readings
|
||||
- Office BP at each visit
|
||||
- Labs (BMP for K+, creatinine) 1-2 weeks after ACE/ARB initiation, then annually
|
||||
|
||||
**Heart Failure**:
|
||||
- Daily weights (report gain >2-3 lbs in 2 days)
|
||||
- BNP/NT-proBNP when clinically changing
|
||||
- Echo annually or if EF change suspected
|
||||
- Medication titration every 2 weeks during optimization phase
|
||||
|
||||
### Primary Care Integration
|
||||
|
||||
**Preventive Care**:
|
||||
- Include age-appropriate cancer screenings
|
||||
- Vaccination schedule (flu, pneumococcal, zoster, COVID)
|
||||
- Lifestyle counseling (tobacco, alcohol, diet, exercise)
|
||||
|
||||
**Chronic Disease Management Models**:
|
||||
- Chronic Care Model components: Self-management support, delivery system redesign, clinical information systems, decision support
|
||||
- Team-based care: Involvement of nurses, pharmacists, dietitians, care coordinators
|
||||
|
||||
---
|
||||
|
||||
## 2. Rehabilitation Treatment Plans
|
||||
|
||||
### Applicable Settings
|
||||
- Post-acute inpatient rehabilitation
|
||||
- Outpatient PT/OT/SLP
|
||||
- Home health therapy
|
||||
- Skilled nursing facility rehabilitation
|
||||
|
||||
### Key Assessment Components
|
||||
|
||||
**Functional Assessments (use validated tools)**:
|
||||
- **FIM** (Functional Independence Measure): 18 items, 7-point scale, 126 total - most widely used
|
||||
- **Barthel Index**: 10 ADLs, 100-point scale - simpler than FIM
|
||||
- **Berg Balance Scale**: 14 tasks, 56 points - fall risk (score <45 = high risk)
|
||||
- **6-Minute Walk Test**: Distance walked in 6 minutes - cardiopulmonary endurance
|
||||
- **Timed Up and Go (TUG)**: Time to stand, walk 3 meters, turn, return, sit - fall risk (>12 sec = high risk)
|
||||
- **9-Hole Peg Test**: Upper extremity fine motor speed
|
||||
- **ROM**: Goniometric measurement for each joint
|
||||
- **Manual Muscle Testing**: 0-5 scale (0=no contraction, 5=normal strength)
|
||||
|
||||
**ICF Framework Goals**:
|
||||
- **Body Functions/Structures**: Impairments (ROM, strength, balance)
|
||||
- **Activity**: Task performance (walk 150 feet, dress independently)
|
||||
- **Participation**: Life roles (return to work, community engagement)
|
||||
|
||||
### Rehabilitation Goals Specifics
|
||||
|
||||
**Goal Levels**:
|
||||
1. **Impairment Goals**: Increase knee ROM 90→110°, improve MMT 3/5→4/5
|
||||
2. **Activity Goals**: Ambulate 300 feet with walker, transfer bed-chair independently
|
||||
3. **Participation Goals**: Return to work, resume hobbies, live independently
|
||||
|
||||
**Assistance Levels** (document current and goal):
|
||||
- I = Independent
|
||||
- SV = Supervision (cues, no physical assist)
|
||||
- CG = Contact Guard (hands close, no assist)
|
||||
- Min A = Minimal Assist (patient does 75%+)
|
||||
- Mod A = Moderate Assist (patient does 50-74%)
|
||||
- Max A = Maximal Assist (patient does 25-49%)
|
||||
- Total A = Total Assist (patient does <25%)
|
||||
|
||||
### Therapy Interventions
|
||||
|
||||
**Physical Therapy**:
|
||||
- Therapeutic exercise dose: Specify sets, reps, resistance, frequency
|
||||
- Gait training: Distance, assistive device, supervision level
|
||||
- Balance training: Static, dynamic, perturbation-based
|
||||
- Modalities: Heat, ice, TENS, E-stim - adjuncts only, not primary intervention
|
||||
|
||||
**Occupational Therapy**:
|
||||
- ADL training: Use of adaptive equipment (reacher, sock aid, built-up utensils)
|
||||
- Upper extremity strengthening: Functional tasks, fine motor activities
|
||||
- Cognitive retraining: Memory strategies, attention training, executive function
|
||||
|
||||
**Speech-Language Pathology**:
|
||||
- Dysphagia: Diet texture modifications (IDDSI levels), swallow strategies (chin tuck, multiple swallows)
|
||||
- Aphasia therapy: Constraint-induced language therapy, semantic feature analysis
|
||||
- Dysarthria: Articulation drills, rate control, augmentative communication
|
||||
|
||||
### Home Exercise Program (HEP)
|
||||
|
||||
**Essentials**:
|
||||
- Illustrated handout with pictures/descriptions
|
||||
- Specific dosage (e.g., "2 sets x 10 reps, daily")
|
||||
- Progression criteria
|
||||
- Safety precautions
|
||||
- Patient/caregiver demonstrates understanding
|
||||
|
||||
### DME and Environmental Modifications
|
||||
|
||||
**Common DME**:
|
||||
- Ambulation: Walker, cane, crutches (specify type, e.g., front-wheeled walker)
|
||||
- Bathroom: Raised toilet seat, shower chair, grab bars
|
||||
- Dressing: Reacher, sock aid, long shoe horn, button hook, elastic laces
|
||||
- Mobility: Hospital bed, wheelchair (if needed)
|
||||
|
||||
**Home Modifications**:
|
||||
- Ramp for stairs
|
||||
- Stair lift if multiple levels
|
||||
- Remove scatter rugs (fall hazard)
|
||||
- Improve lighting
|
||||
- Rearrange for accessibility
|
||||
|
||||
### Discharge Planning
|
||||
|
||||
**Discharge Criteria**:
|
||||
- Functional plateau reached or goals met
|
||||
- Safe for discharge setting
|
||||
- Patient/caregiver educated
|
||||
- DME obtained and home modifications complete
|
||||
- Follow-up arranged
|
||||
|
||||
**Discharge Destination**:
|
||||
- Home with outpatient therapy
|
||||
- Home with home health
|
||||
- Skilled nursing facility
|
||||
- Long-term acute care hospital (if medically complex)
|
||||
|
||||
---
|
||||
|
||||
## 3. Mental Health Treatment Plans
|
||||
|
||||
### Applicable Conditions
|
||||
- Major depressive disorder, dysthymia
|
||||
- Anxiety disorders (GAD, panic, social anxiety, specific phobias)
|
||||
- Bipolar disorder
|
||||
- Schizophrenia and psychotic disorders
|
||||
- PTSD and trauma-related disorders
|
||||
- Eating disorders
|
||||
- Substance use disorders
|
||||
- Personality disorders
|
||||
|
||||
### Key Assessment Components
|
||||
|
||||
**Diagnostic Assessment**:
|
||||
- Meet DSM-5 criteria for diagnosis
|
||||
- Symptom severity assessment (use validated scales)
|
||||
- Functional impairment (work, relationships, self-care)
|
||||
- Psychiatric history (prior episodes, treatments, hospitalizations)
|
||||
- Substance use assessment (AUDIT, DAST)
|
||||
- Trauma history
|
||||
- Family psychiatric history
|
||||
|
||||
**Validated Assessment Tools**:
|
||||
- **PHQ-9**: Depression severity (0-27, scores ≥10 indicate moderate-severe depression)
|
||||
- **GAD-7**: Anxiety severity (0-21, scores ≥10 indicate moderate-severe anxiety)
|
||||
- **MDQ** (Mood Disorder Questionnaire): Bipolar screening
|
||||
- **PC-PTSD-5**: PTSD screening, then full PCL-5 if positive
|
||||
- **AUDIT**: Alcohol use (0-40, ≥8 indicates hazardous drinking)
|
||||
- **PHQ-15**: Somatic symptoms
|
||||
- **WHODAS 2.0**: Functional disability
|
||||
|
||||
**Risk Assessment**:
|
||||
- **Suicide Risk**: Use Columbia Suicide Severity Rating Scale (C-SSRS)
|
||||
- Ideation (passive, active, plan, intent)
|
||||
- Protective factors (reasons for living, social support)
|
||||
- Risk factors (prior attempts, impulsivity, access to means)
|
||||
- **Violence/Homicide Risk**: History of violence, current ideation, access to weapons
|
||||
|
||||
### Treatment Goals Specifics
|
||||
|
||||
**Symptom Goals**:
|
||||
- Reduction in standardized scale scores (e.g., PHQ-9 from 18→<10→<5 for remission)
|
||||
- Specific symptom targets (sleep 7 hours, reduce panic attacks from 3/week→0)
|
||||
|
||||
**Functional Goals**:
|
||||
- Return to work/school
|
||||
- Resume social activities
|
||||
- Improve relationships
|
||||
- Self-care independence
|
||||
|
||||
**Recovery-Oriented Goals**:
|
||||
- Personal meaning and purpose
|
||||
- Hope and empowerment
|
||||
- Social connections and community integration
|
||||
- Independent living
|
||||
|
||||
### Evidence-Based Psychotherapies
|
||||
|
||||
**Depression**:
|
||||
- **CBT**: 12-16 sessions, homework between sessions
|
||||
- **Behavioral Activation**: Focus on increasing rewarding activities
|
||||
- **Interpersonal Therapy (IPT)**: 12-16 sessions, focus on relationships
|
||||
- **Problem-Solving Therapy**: Brief (6-8 sessions), structured approach
|
||||
|
||||
**Anxiety**:
|
||||
- **CBT with exposure**: Gold standard for anxiety disorders
|
||||
- **Panic Control Therapy**: Interoceptive exposure, cognitive restructuring
|
||||
- **Social skills training**: For social anxiety
|
||||
|
||||
**PTSD**:
|
||||
- **Prolonged Exposure (PE)**: 8-15 sessions, imaginal and in vivo exposure
|
||||
- **Cognitive Processing Therapy (CPT)**: 12 sessions, challenge trauma-related cognitions
|
||||
- **EMDR** (Eye Movement Desensitization and Reprocessing): Alternative, less evidence than PE/CPT
|
||||
|
||||
**Bipolar**:
|
||||
- **Family-Focused Therapy**: Psychoeducation, communication, problem-solving
|
||||
- **Interpersonal and Social Rhythm Therapy**: Stabilize daily routines, sleep
|
||||
|
||||
**Borderline Personality Disorder**:
|
||||
- **DBT** (Dialectical Behavior Therapy): 1 year program, individual + group + phone coaching
|
||||
- Skills: Mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness
|
||||
|
||||
### Psychopharmacology Specifics
|
||||
|
||||
**Antidepressants**:
|
||||
- First-line: SSRIs (sertraline, escitalopram, fluoxetine)
|
||||
- 2-4 weeks for initial response, 6-8 weeks for full effect
|
||||
- Titrate after 2-4 weeks if partial response
|
||||
- Switch if no response after full trial
|
||||
- Augmentation strategies if partial response (second antidepressant, atypical antipsychotic, lithium)
|
||||
- Continue 6-12 months after remission (longer if recurrent)
|
||||
|
||||
**Antipsychotics**:
|
||||
- First-generation (typical): Haloperidol - high EPS risk, use second-generation preferred
|
||||
- Second-generation (atypical): Risperidone, olanzapine, quetiapine, aripiprazole, lurasidone
|
||||
- Monitoring: Metabolic syndrome (weight, glucose, lipids), EPS, prolactin, QTc
|
||||
|
||||
**Mood Stabilizers**:
|
||||
- Lithium: Narrow therapeutic window, monitor levels (0.6-1.2 mEq/L), TSH, renal function
|
||||
- Valproic acid: Monitor levels, LFTs, CBC (thrombocytopenia)
|
||||
- Lamotrigine: Titrate slowly (risk of Stevens-Johnson syndrome if too fast)
|
||||
|
||||
### Safety Planning
|
||||
|
||||
**Essential for All Mental Health Plans**:
|
||||
- Warning signs (thoughts, feelings, behaviors)
|
||||
- Internal coping strategies
|
||||
- Social support contacts
|
||||
- Professional contacts (therapist, psychiatrist, crisis line)
|
||||
- Means restriction (firearms removed, medications limited)
|
||||
- Reason for living
|
||||
|
||||
**Crisis Resources**:
|
||||
- 988 Suicide & Crisis Lifeline
|
||||
- Crisis Text Line (text HOME to 741741)
|
||||
- Local mobile crisis team
|
||||
- Emergency department
|
||||
|
||||
---
|
||||
|
||||
## 4. Chronic Disease Management Plans
|
||||
|
||||
### Multiple Comorbidities Management
|
||||
|
||||
**Common Clusters**:
|
||||
- Cardiometabolic: Diabetes + hypertension + hyperlipidemia + obesity
|
||||
- Cardiopulmonary: Heart failure + COPD
|
||||
- Renal-cardiovascular: CKD + hypertension + diabetes
|
||||
- Mental-physical: Depression + chronic pain + chronic disease
|
||||
|
||||
### Prioritization Strategies
|
||||
|
||||
**When Multiple Goals Compete**:
|
||||
1. **Life-threatening issues first**: Unstable angina, uncontrolled heart failure
|
||||
2. **High-impact, modifiable conditions**: Diabetes with HbA1c 10% (significant reduction possible)
|
||||
3. **Synergistic treatments**: Medications that help multiple conditions (SGLT2i for diabetes + heart failure + CKD)
|
||||
4. **Patient priorities**: What matters most to patient
|
||||
|
||||
### Medication Optimization for Multimorbidity
|
||||
|
||||
**Synergistic Medications** (dual/triple benefit):
|
||||
- **SGLT2 inhibitors**: Diabetes + heart failure + CKD
|
||||
- **ACE inhibitors/ARBs**: Hypertension + diabetes (renal protection) + heart failure
|
||||
- **Beta-blockers**: Hypertension + heart failure + CAD
|
||||
- **Statins**: Hyperlipidemia + ASCVD prevention + diabetes
|
||||
- **GLP-1 agonists**: Diabetes + weight loss + cardiovascular benefit
|
||||
|
||||
**Deprescribing**:
|
||||
- Identify medications with limited benefit (e.g., strict glycemic control in limited life expectancy)
|
||||
- Discontinue medications with more harm than benefit
|
||||
- Simplify regimens (reduce pill burden)
|
||||
|
||||
### Care Coordination
|
||||
|
||||
**Team-Based Care**:
|
||||
- Primary care coordinates
|
||||
- Specialists co-manage (cardiologist for HF, endocrinologist for diabetes)
|
||||
- Care coordinator facilitates (schedules, education, barrier identification)
|
||||
- Pharmacist reviews medications, optimizes therapy
|
||||
- Dietitian provides medical nutrition therapy
|
||||
- Social worker addresses social needs
|
||||
|
||||
**Communication**:
|
||||
- Shared EHR when possible
|
||||
- Care plan accessible to all team members
|
||||
- Medication reconciliation after specialist visits
|
||||
- Regular team meetings or e-consultations
|
||||
|
||||
### Population Health Integration
|
||||
|
||||
**Registry Management**:
|
||||
- Identify patients due for care (HbA1c testing, diabetic eye exam)
|
||||
- Outreach for overdue preventive care
|
||||
- Risk stratification (high-utilizers, complex patients)
|
||||
|
||||
**Transition Management**:
|
||||
- Hospital discharge follow-up within 7 days
|
||||
- Medication reconciliation post-discharge
|
||||
- Red flags review
|
||||
- Escalation plan if decompensating
|
||||
|
||||
---
|
||||
|
||||
## 5. Perioperative Care Plans
|
||||
|
||||
### Preoperative Risk Assessment
|
||||
|
||||
**Cardiac Risk** (Revised Cardiac Risk Index - RCRI):
|
||||
- High-risk surgery, ischemic heart disease, heart failure, CVD, diabetes on insulin, creatinine >2
|
||||
- 0 points = <1% risk, 1 point = 1%, 2 points = 2.4%, ≥3 points = 5.4% risk of cardiac event
|
||||
|
||||
**If High Risk**: Consider further testing (stress test, echo), cardiology consultation, perioperative beta-blockade.
|
||||
|
||||
**Pulmonary Risk** (ARISCAT score):
|
||||
- Age, SpO2, respiratory infection recent, preop anemia, surgical incision, duration, emergency
|
||||
- Higher risk: Smoking cessation, incentive spirometry, early mobilization
|
||||
|
||||
**VTE Risk** (Caprini Score):
|
||||
- Age, surgery type, mobility, prior VTE, obesity, cancer
|
||||
- Stratify to guide prophylaxis (none, mechanical, pharmacologic, or both)
|
||||
|
||||
### Preoperative Optimization
|
||||
|
||||
**Diabetes**:
|
||||
- Target HbA1c <8% for elective surgery (delay if >9%)
|
||||
- Hold metformin 24-48 hours before (risk of lactic acidosis)
|
||||
- Hold SGLT2i 3-4 days before (DKA risk)
|
||||
- Insulin: Reduce long-acting by 20-25% day of surgery, hold short-acting
|
||||
|
||||
**Hypertension**:
|
||||
- Continue most medications through surgery
|
||||
- Hold ACE/ARB morning of surgery (avoid intraop hypotension)
|
||||
- Continue beta-blocker (avoid withdrawal)
|
||||
|
||||
**Anticoagulation**:
|
||||
- Warfarin: Hold 5 days before, bridge with LMWH if high VTE risk
|
||||
- DOACs: Hold 24-48 hours (based on renal function and bleeding risk)
|
||||
- Antiplatelet: Continue aspirin for most surgeries, hold P2Y12 inhibitors (clopidogrel) 5-7 days if high bleeding risk
|
||||
|
||||
**Anemia**:
|
||||
- Optimize iron stores preop (IV iron if time limited)
|
||||
- Avoid transfusion triggers if possible (restrictive strategy)
|
||||
|
||||
### Enhanced Recovery After Surgery (ERAS)
|
||||
|
||||
**Preoperative**:
|
||||
- Patient education, expectation setting
|
||||
- No prolonged fasting (clear liquids 2 hours before)
|
||||
- Carbohydrate loading (reduces insulin resistance)
|
||||
- No routine premedication
|
||||
|
||||
**Intraoperative**:
|
||||
- Multimodal analgesia (minimize opioids)
|
||||
- Goal-directed fluid therapy (avoid overhydration)
|
||||
- Normothermia (prevent hypothermia)
|
||||
- Antiemetic prophylaxis
|
||||
|
||||
**Postoperative**:
|
||||
- Early mobilization (out of bed day of surgery)
|
||||
- Early oral nutrition (resume diet POD 0-1)
|
||||
- Multimodal analgesia (acetaminophen, NSAIDs, regional blocks)
|
||||
- Remove tubes/drains early (Foley, NG tube, surgical drains)
|
||||
- DVT prophylaxis
|
||||
|
||||
### Postoperative Milestones
|
||||
|
||||
**Day of Surgery (POD 0)**:
|
||||
- Out of bed to chair 4-6 hours post-op
|
||||
- Sips of clear liquids if appropriate
|
||||
- Pain controlled on multimodal regimen
|
||||
|
||||
**POD 1**:
|
||||
- Ambulate in hallway
|
||||
- Regular diet
|
||||
- Foley catheter removed
|
||||
- Transition to oral pain medications
|
||||
|
||||
**POD 2-3** (typical discharge for many surgeries):
|
||||
- Ambulate 150+ feet
|
||||
- Adequate oral intake
|
||||
- Pain controlled on oral meds
|
||||
- No complications requiring hospitalization
|
||||
|
||||
### Discharge Readiness
|
||||
|
||||
**Criteria**:
|
||||
- Adequate pain control on oral medications
|
||||
- Tolerating regular diet
|
||||
- Mobile (ambulate, transfers)
|
||||
- Voiding spontaneously
|
||||
- Stable vital signs
|
||||
- No active complications
|
||||
- Safe discharge plan (home support, DME arranged)
|
||||
|
||||
---
|
||||
|
||||
## 6. Pain Management Plans
|
||||
|
||||
### Pain Assessment
|
||||
|
||||
**Comprehensive Pain Evaluation**:
|
||||
- Location, radiation
|
||||
- Quality (sharp, dull, burning, aching, shooting)
|
||||
- Intensity (0-10 NRS)
|
||||
- Temporal pattern (constant, intermittent, episodic)
|
||||
- Aggravating/alleviating factors
|
||||
- Functional impact (Brief Pain Inventory - BPI interference items)
|
||||
- Prior treatments and responses
|
||||
|
||||
**Pain Classification**:
|
||||
- **Nociceptive**: Somatic (MSK) or visceral (organ)
|
||||
- **Neuropathic**: Nerve injury/dysfunction (burning, shooting, electric, numbness/tingling)
|
||||
- **Nociplastic**: Central sensitization, fibromyalgia
|
||||
- **Mixed**: Combination
|
||||
|
||||
### Multimodal Analgesia Principles
|
||||
|
||||
**Goal**: Additive/synergistic pain relief from multiple mechanisms, opioid-sparing.
|
||||
|
||||
**Components**:
|
||||
1. Non-opioid analgesics (acetaminophen, NSAIDs)
|
||||
2. Adjuvant analgesics (gabapentinoids, SNRIs, TCAs for neuropathic)
|
||||
3. Topical agents (lidocaine patches, diclofenac gel, capsaicin)
|
||||
4. Interventional procedures (injections, nerve blocks, RFA, SCS)
|
||||
5. Physical therapies (PT, exercise, TENS)
|
||||
6. Psychological therapies (CBT-CP, mindfulness, biofeedback)
|
||||
7. Complementary therapies (acupuncture, massage, yoga)
|
||||
8. Opioids (if other modalities insufficient) - lowest dose, reassess frequently
|
||||
|
||||
### Neuropathic Pain Specific Treatments
|
||||
|
||||
**First-Line**:
|
||||
- Gabapentin 300mg titrate to 1800-3600mg/day divided TID
|
||||
- Pregabalin 75mg BID titrate to 150-300mg BID
|
||||
- Duloxetine 60mg daily (also for fibromyalgia, chronic MSK pain)
|
||||
- TCAs (amitriptyline, nortriptyline) 10-75mg QHS - second-line due to side effects
|
||||
|
||||
**Topical**:
|
||||
- Lidocaine patches 5% (localized neuropathic pain)
|
||||
- Capsaicin 8% patch (high-concentration, applied by provider)
|
||||
|
||||
**Refractory**:
|
||||
- Tramadol (dual mechanism - opioid + SNRI)
|
||||
- Opioids (if severe and function-limiting despite above)
|
||||
|
||||
### Opioid Prescribing (CDC Guidelines)
|
||||
|
||||
**Before Initiating**:
|
||||
- Non-opioid multimodal therapies tried and inadequate
|
||||
- Functional goals established (not just pain scores)
|
||||
- Risks vs. benefits discussed and documented
|
||||
- Opioid risk assessment (ORT, SOAPP)
|
||||
- Informed consent discussion
|
||||
- Treatment agreement signed
|
||||
- PDMP checked
|
||||
- Baseline UDS
|
||||
|
||||
**During Opioid Therapy**:
|
||||
- Start low dose (<50 MME/day), short-acting
|
||||
- Reassess frequently (every 1-3 months)
|
||||
- Functional improvement expected (not just pain scores)
|
||||
- UDS every 3-6 months (check for adherence and illicit substances)
|
||||
- PDMP check each prescription or at least every 3 months
|
||||
- Naloxone co-prescribed
|
||||
- Avoid concurrent benzodiazepines
|
||||
- If dose approaching 50 MME, reassess; avoid >90 MME if possible
|
||||
|
||||
**Tapering**:
|
||||
- If not meeting functional goals
|
||||
- Serious adverse effects
|
||||
- Aberrant behaviors
|
||||
- Patient request
|
||||
- Slow taper: 10-25% dose reduction per week to month (faster if safety concern)
|
||||
|
||||
### Interventional Pain Procedures
|
||||
|
||||
**Indications and Evidence**:
|
||||
- **Epidural Steroid Injection**: Radicular pain from disc herniation/stenosis - short-term benefit
|
||||
- **Facet Joint Injections**: Diagnostic (if >50% relief, proceed to RFA)
|
||||
- **Radiofrequency Ablation**: 6-12 months relief for facet-mediated pain
|
||||
- **Spinal Cord Stimulation**: Refractory neuropathic pain (FBSS, CRPS) - 50-60% success
|
||||
- **Intrathecal Pump**: Severe refractory pain, cancer pain - delivers medication to CSF
|
||||
|
||||
**Documentation for Procedures**:
|
||||
- Indication, prior conservative treatments tried
|
||||
- Expected benefit and duration
|
||||
- Risks discussed
|
||||
- Number of injections/procedures allowed per year
|
||||
|
||||
### Functional Goals Emphasis
|
||||
|
||||
**Shift from Pain Scores to Function**:
|
||||
- "Reduce pain to 3/10" is less meaningful than "Walk 1 mile, return to work, play with grandchildren"
|
||||
- BPI interference scores track functional impact
|
||||
- SMART functional goals (see Goal Setting reference)
|
||||
|
||||
### Psychological Integration
|
||||
|
||||
**CBT for Chronic Pain (CBT-CP)**:
|
||||
- Pain education and reconceptualization (pain ≠ harm)
|
||||
- Cognitive restructuring (challenge catastrophizing, all-or-nothing thinking)
|
||||
- Activity pacing and graded exposure (increase activity without flares)
|
||||
- Relaxation techniques
|
||||
- Acceptance and mindfulness
|
||||
|
||||
**Essential for Chronic Pain**: Psychological factors (depression, anxiety, catastrophizing) perpetuate pain; must be addressed.
|
||||
|
||||
---
|
||||
|
||||
## Cross-Cutting Considerations for All Treatment Plans
|
||||
|
||||
### Cultural Competence
|
||||
- Ask about cultural health beliefs, practices
|
||||
- Use interpreter services when language barriers exist
|
||||
- Respect religious/spiritual practices in treatment
|
||||
- Adapt interventions to cultural context when possible
|
||||
|
||||
### Health Literacy
|
||||
- Assess understanding (teach-back method)
|
||||
- Use plain language, avoid jargon
|
||||
- Visual aids, written materials at 5th-6th grade reading level
|
||||
- Confirm patient can execute plan (demonstrate inhaler use, insulin injection, etc.)
|
||||
|
||||
### Social Determinants of Health (SDOH)
|
||||
- Screen for food insecurity, housing instability, transportation barriers
|
||||
- Connect to community resources (SNAP, Medicaid, patient assistance programs)
|
||||
- Address barriers in treatment plan (e.g., medication cost → generic alternatives, patient assistance)
|
||||
|
||||
### Advance Care Planning
|
||||
- Appropriate for serious illness, elderly, declining function
|
||||
- Goals of care discussion
|
||||
- Healthcare proxy designation
|
||||
- Advance directive completion
|
||||
- Preferences for resuscitation, intubation, dialysis, etc.
|
||||
|
||||
---
|
||||
|
||||
**Document Version**: 1.0
|
||||
**Last Updated**: January 2025
|
||||
**Next Review**: January 2026
|
||||
|
||||
485
skills/treatment-plans/references/treatment_plan_standards.md
Normal file
485
skills/treatment-plans/references/treatment_plan_standards.md
Normal file
@@ -0,0 +1,485 @@
|
||||
% Treatment Plan Standards and Best Practices
|
||||
% Professional guidelines for treatment plan documentation
|
||||
% Last updated: 2025
|
||||
|
||||
# Treatment Plan Standards
|
||||
|
||||
## Overview
|
||||
|
||||
Treatment plans are comprehensive documents that outline systematic approaches to addressing patient health conditions through evidence-based interventions, measurable goals, and structured follow-up. This reference provides professional standards, documentation requirements, and legal considerations for creating high-quality treatment plans across all medical specialties.
|
||||
|
||||
## Core Documentation Standards
|
||||
|
||||
### 1. Executive Summary Best Practices (Foundation Medicine Model)
|
||||
|
||||
**CRITICAL: All treatment plans MUST include a prominent "Treatment Plan Highlights" summary box on the first page.**
|
||||
|
||||
Following the Foundation Medicine model for genomic profiling reports, treatment plans should begin with a concise, bulletin-style summary that provides immediate access to key actionable information:
|
||||
|
||||
**Components of Treatment Plan Highlights Box:**
|
||||
- **Key Diagnosis**: Primary condition with ICD-10 code, severity/stage (1 line)
|
||||
- **Primary Treatment Goals**: 2-3 SMART goals in bullet format
|
||||
- **Main Interventions**: 2-3 key interventions (pharmacological, non-pharmacological, monitoring)
|
||||
- **Timeline Overview**: Brief treatment duration/phases (1 line)
|
||||
|
||||
**Format Requirements:**
|
||||
- Use colored box (tcolorbox in LaTeX) to make it visually prominent
|
||||
- Place immediately after title, before Patient Information section
|
||||
- Summary must fit on first page with patient demographics
|
||||
- Use concise, actionable language
|
||||
- Focus on what clinicians need to know immediately
|
||||
|
||||
**Optimal Document Length:**
|
||||
- **Preferred**: 1 page for most treatment plans (quick-reference format)
|
||||
- **Standard**: 3-4 pages for moderate complexity cases
|
||||
- **Extended**: 5-6 pages maximum for highly complex cases only
|
||||
- Prioritize brevity, clarity, and actionability over comprehensive detail
|
||||
- Think "clinical decision support card" not "comprehensive textbook"
|
||||
|
||||
**Design Philosophy:**
|
||||
The highlights box enables efficient clinical decision-making by providing critical information upfront, following evidence-based practices from precision medicine reporting. This approach improves care coordination, reduces time to treatment initiation, and ensures key information is never overlooked.
|
||||
|
||||
### 2. Essential Components
|
||||
|
||||
All treatment plans must include:
|
||||
|
||||
#### Patient Information (De-identified for Sharing)
|
||||
- Unique patient identifier (not name or MRN)
|
||||
- Age range (not exact birth date)
|
||||
- Relevant demographics
|
||||
- Date of plan creation
|
||||
- Provider name and credentials
|
||||
- HIPAA compliance statement
|
||||
|
||||
#### Diagnosis and Assessment
|
||||
- Primary diagnosis with ICD-10 code
|
||||
- Secondary diagnoses and comorbidities
|
||||
- Severity classification or staging
|
||||
- Functional assessment and baseline status
|
||||
- Risk stratification
|
||||
- Prognostic considerations
|
||||
|
||||
#### Treatment Goals (SMART Format)
|
||||
- **Specific**: Clearly defined outcomes
|
||||
- **Measurable**: Quantifiable metrics or observable criteria
|
||||
- **Achievable**: Realistic given patient circumstances
|
||||
- **Relevant**: Aligned with patient values and priorities
|
||||
- **Time-bound**: Defined timeframe for achievement
|
||||
|
||||
Short-term goals (weeks to 3 months) and long-term goals (3-12+ months) should be distinguished.
|
||||
|
||||
#### Interventions
|
||||
- **Pharmacological**: Specific medications, doses, frequencies, rationales
|
||||
- **Non-pharmacological**: Lifestyle modifications, behavioral interventions, education
|
||||
- **Procedural**: Planned procedures, specialist referrals, diagnostic testing
|
||||
|
||||
#### Timeline and Schedule
|
||||
- Treatment phases with durations
|
||||
- Appointment frequency
|
||||
- Milestone assessments
|
||||
- Expected treatment duration
|
||||
|
||||
#### Monitoring Parameters
|
||||
- Clinical outcomes to track
|
||||
- Assessment tools and scales
|
||||
- Monitoring frequency
|
||||
- Intervention thresholds
|
||||
|
||||
#### Expected Outcomes
|
||||
- Primary outcome measures
|
||||
- Success criteria
|
||||
- Timeline for improvement
|
||||
- Criteria for treatment modification
|
||||
|
||||
#### Follow-up Plan
|
||||
- Scheduled appointments
|
||||
- Communication protocols
|
||||
- Emergency procedures
|
||||
- Transition planning
|
||||
|
||||
#### Patient Education
|
||||
- Condition understanding
|
||||
- Self-management skills
|
||||
- Warning signs
|
||||
- Resources and support
|
||||
|
||||
#### Risk Mitigation
|
||||
- Potential adverse effects
|
||||
- Safety monitoring
|
||||
- Emergency action plans
|
||||
- Complication prevention
|
||||
|
||||
### 2. Professional Documentation Standards
|
||||
|
||||
#### Clarity and Precision
|
||||
- Use professional medical terminology appropriately
|
||||
- Define abbreviations on first use
|
||||
- Avoid ambiguous language
|
||||
- Specific rather than vague descriptions
|
||||
|
||||
**Good Example**: "Reduce HbA1c from 8.5% to <7% within 3 months"
|
||||
**Poor Example**: "Improve diabetes control"
|
||||
|
||||
#### Completeness
|
||||
- Address all relevant aspects of condition
|
||||
- Include rationale for treatment choices
|
||||
- Document shared decision-making
|
||||
- Address patient preferences and concerns
|
||||
|
||||
#### Accuracy
|
||||
- Factually correct information
|
||||
- Current evidence-based recommendations
|
||||
- Appropriate dosing and frequencies
|
||||
- Correct ICD-10 and CPT codes
|
||||
|
||||
#### Timeliness
|
||||
- Plans created at diagnosis or treatment initiation
|
||||
- Updated after significant clinical changes
|
||||
- Regular scheduled updates (quarterly to annually)
|
||||
- Dated and signed promptly
|
||||
|
||||
#### Legibility and Organization
|
||||
- Professional formatting
|
||||
- Logical flow and structure
|
||||
- Consistent use of headings and sections
|
||||
- Easy to locate key information
|
||||
|
||||
### 3. Legal and Regulatory Requirements
|
||||
|
||||
#### Medical Necessity Documentation
|
||||
Treatment plans must demonstrate:
|
||||
- Appropriateness of interventions for diagnosis
|
||||
- Evidence supporting treatment choices
|
||||
- Expected outcomes justify costs and risks
|
||||
- Frequency and duration are reasonable
|
||||
- Less invasive options considered
|
||||
|
||||
#### Informed Consent Documentation
|
||||
Record that patient:
|
||||
- Understands diagnosis and prognosis
|
||||
- Aware of treatment options, risks, and benefits
|
||||
- Knows alternatives to proposed treatment
|
||||
- Had opportunity to ask questions
|
||||
- Voluntarily agrees to treatment plan
|
||||
|
||||
#### Privacy and Confidentiality (HIPAA)
|
||||
- Protected Health Information (PHI) safeguarded
|
||||
- De-identification for sharing:
|
||||
- Remove 18 HIPAA identifiers per Safe Harbor method
|
||||
- Names, dates (except year), geographic subdivisions smaller than state
|
||||
- Contact information (phone, fax, email, addresses)
|
||||
- Social Security numbers, medical record numbers, account numbers
|
||||
- Biometric identifiers, photos, other unique identifiers
|
||||
- Access limited to those with treatment, payment, or operations need
|
||||
- Patient authorization for non-routine disclosures
|
||||
|
||||
#### Billing and Reimbursement Support
|
||||
- ICD-10 diagnosis codes for all conditions
|
||||
- CPT codes for procedures
|
||||
- Documentation of medical necessity
|
||||
- Justification for level of service
|
||||
- Compliance with payer-specific requirements
|
||||
|
||||
#### Quality Measure Reporting
|
||||
Enable extraction of quality metrics:
|
||||
- HEDIS measures (diabetes HbA1c testing, BP control, etc.)
|
||||
- CMS quality reporting (MIPS, ACO measures)
|
||||
- Disease-specific quality indicators
|
||||
- Patient safety indicators
|
||||
|
||||
#### Liability Protection
|
||||
Defensible documentation includes:
|
||||
- Rationale for clinical decisions
|
||||
- Consideration of differential diagnosis
|
||||
- Risk-benefit analysis
|
||||
- Patient education and warnings
|
||||
- Follow-up plan for abnormal findings
|
||||
- Addressing non-adherence or patient refusal
|
||||
|
||||
## Professional Practice Standards
|
||||
|
||||
### Joint Commission Standards
|
||||
|
||||
#### Patient-Centered Care
|
||||
- Treatment plans developed with patient participation
|
||||
- Goals reflect patient values and preferences
|
||||
- Cultural and linguistic needs addressed
|
||||
- Health literacy appropriate communication
|
||||
|
||||
#### Multidisciplinary Coordination
|
||||
- Input from relevant disciplines
|
||||
- Clear role delineation
|
||||
- Communication among team members
|
||||
- Coordinated interventions
|
||||
|
||||
#### Evidence-Based Practice
|
||||
- Interventions based on current evidence
|
||||
- Clinical practice guidelines followed
|
||||
- Variation from guidelines documented and justified
|
||||
- Literature supports treatment choices
|
||||
|
||||
### Commission on Accreditation of Rehabilitation Facilities (CARF)
|
||||
|
||||
For rehabilitation treatment plans:
|
||||
- Individualized based on comprehensive assessment
|
||||
- Measurable, achievable, time-specific goals
|
||||
- Regular team review and modification
|
||||
- Patient and family involvement
|
||||
- Transition and discharge planning
|
||||
|
||||
### Centers for Medicare & Medicaid Services (CMS)
|
||||
|
||||
#### Conditions of Participation
|
||||
- Physician orders for treatment
|
||||
- Periodic review and revision
|
||||
- Progress toward goals documented
|
||||
- Care plan accessible to all team members
|
||||
|
||||
#### Documentation Requirements
|
||||
- Legible (typed or clear handwriting)
|
||||
- Dated and authenticated (signed)
|
||||
- Amendments/corrections properly marked
|
||||
- Retention per state law (typically 7-10 years, longer for minors)
|
||||
|
||||
## Medical Specialty Standards
|
||||
|
||||
### Primary Care
|
||||
- Annual comprehensive assessment and plan update
|
||||
- Chronic disease management protocols
|
||||
- Preventive care integration
|
||||
- Medication reconciliation
|
||||
- Care coordination with specialists
|
||||
|
||||
### Behavioral Health
|
||||
- Mental status examination
|
||||
- Psychiatric diagnoses per DSM-5 criteria
|
||||
- Suicide/homicide risk assessment and safety planning
|
||||
- Measurable behavioral outcomes
|
||||
- Crisis intervention plan
|
||||
- Substance use assessment
|
||||
- 42 CFR Part 2 compliance for substance use treatment
|
||||
|
||||
### Rehabilitation
|
||||
- Functional assessments (FIM, Barthel Index, etc.)
|
||||
- Activity limitations and participation restrictions
|
||||
- Short-term and long-term functional goals
|
||||
- Therapy frequency, intensity, duration
|
||||
- Home exercise program
|
||||
- Assistive devices and DME
|
||||
- Discharge criteria
|
||||
|
||||
### Surgical/Perioperative
|
||||
- Indication for surgery documented
|
||||
- Preoperative risk assessment (ASA, RCRI)
|
||||
- Medical optimization plan
|
||||
- Enhanced Recovery After Surgery (ERAS) protocols when applicable
|
||||
- Postoperative milestones
|
||||
- Discharge criteria and planning
|
||||
|
||||
### Pain Management
|
||||
- Comprehensive pain assessment (location, intensity, quality, temporal pattern, impact)
|
||||
- Pain type (nociceptive, neuropathic, mixed)
|
||||
- Multimodal analgesia approach
|
||||
- Opioid risk assessment (ORT, SOAPP)
|
||||
- If opioids: CDC guidelines compliance, treatment agreement, UDS, PDMP
|
||||
- Functional goals (not just pain scores)
|
||||
- Psychological screening and intervention
|
||||
|
||||
## Quality Indicators for Treatment Plans
|
||||
|
||||
### Completeness Metrics
|
||||
- All required sections present (100%)
|
||||
- Goals meet SMART criteria ($\geq$90%)
|
||||
- Interventions have clear rationales ($\geq$95%)
|
||||
- Monitoring plan includes frequency ($\geq$95%)
|
||||
- Patient education documented (100%)
|
||||
|
||||
### Clinical Quality Metrics
|
||||
- Evidence-based interventions ($\geq$90%)
|
||||
- Guideline-concordant care ($\geq$85%)
|
||||
- Avoidance of low-value care (100%)
|
||||
- Appropriate preventive care included ($\geq$95%)
|
||||
|
||||
### Patient-Centered Metrics
|
||||
- Patient preferences documented ($\geq$90%)
|
||||
- Shared decision-making noted ($\geq$85%)
|
||||
- Culturally appropriate care (100%)
|
||||
- Health literacy addressed ($\geq$90%)
|
||||
|
||||
### Safety Metrics
|
||||
- Risk mitigation strategies present (100%)
|
||||
- Medication safety addressed (100%)
|
||||
- Emergency procedures documented (100%)
|
||||
- Red flags/warning signs communicated (100%)
|
||||
|
||||
## Common Documentation Deficiencies and Solutions
|
||||
|
||||
### Problem: Vague Goals
|
||||
**Deficiency**: "Improve diabetes"
|
||||
**Solution**: "Reduce HbA1c from 8.5% to <7% within 3 months through medication intensification and lifestyle modification"
|
||||
|
||||
### Problem: Missing Rationales
|
||||
**Deficiency**: Lists medications without explanation
|
||||
**Solution**: "Metformin 1000mg BID - first-line therapy for T2DM, reduces hepatic glucose production, target dose for HbA1c reduction"
|
||||
|
||||
### Problem: No Timeline
|
||||
**Deficiency**: Goals without timeframes
|
||||
**Solution**: "Short-term (3 months): HbA1c <7.5%; Long-term (6 months): HbA1c <7%"
|
||||
|
||||
### Problem: Incomplete Monitoring
|
||||
**Deficiency**: "Monitor labs"
|
||||
**Solution**: "HbA1c every 3 months until at goal, then every 6 months; CMP every 6 months to monitor renal function on metformin and ACE inhibitor"
|
||||
|
||||
### Problem: Absent Patient Education
|
||||
**Deficiency**: No documentation of education provided
|
||||
**Solution**: Dedicated section documenting: condition education, self-management skills taught, warning signs communicated, resources provided
|
||||
|
||||
### Problem: Missing Safety Planning
|
||||
**Deficiency**: No risk mitigation
|
||||
**Solution**: Specific safety concerns addressed (e.g., hypoglycemia risk with insulin, monitoring plan, patient taught recognition and treatment)
|
||||
|
||||
## Electronic Health Record (EHR) Integration
|
||||
|
||||
### Structured Data Entry
|
||||
- Use templates for consistency
|
||||
- Coded diagnoses (ICD-10), procedures (CPT)
|
||||
- Structured goals enable outcome tracking
|
||||
- Discrete medication fields (name, dose, route, frequency)
|
||||
|
||||
### Clinical Decision Support
|
||||
- Evidence-based order sets
|
||||
- Drug-drug interaction alerts
|
||||
- Guideline reminders
|
||||
- Quality measure tracking
|
||||
|
||||
### Care Plan Sharing
|
||||
- Patient portal access (patient-friendly version)
|
||||
- Interoperability standards (C-CDA)
|
||||
- Shared with care team
|
||||
- Transitions of care summary
|
||||
|
||||
## Audit and Peer Review
|
||||
|
||||
### Internal Quality Review
|
||||
- Random sample chart audits (e.g., 5% quarterly)
|
||||
- Checklist-based review (completeness, quality)
|
||||
- Feedback to providers
|
||||
- Continuous quality improvement
|
||||
|
||||
### External Review
|
||||
- Payer audits (documentation supports billing)
|
||||
- Regulatory surveys (Joint Commission, CMS)
|
||||
- Malpractice case review
|
||||
- Peer review for privileging/credentialing
|
||||
|
||||
### Audit Criteria
|
||||
- Documentation completeness
|
||||
- Clinical appropriateness
|
||||
- Regulatory compliance
|
||||
- Billing integrity
|
||||
- Patient safety
|
||||
|
||||
## Treatment Plan Revision and Updates
|
||||
|
||||
### When to Update Treatment Plans
|
||||
|
||||
**Scheduled Updates**:
|
||||
- Chronic disease management: Every 3-6 months minimum
|
||||
- Behavioral health: Every 30-90 days depending on acuity
|
||||
- Rehabilitation: Weekly to biweekly during active therapy
|
||||
- Annual comprehensive update for all chronic conditions
|
||||
|
||||
**Triggered Updates**:
|
||||
- Significant change in clinical status
|
||||
- New diagnosis
|
||||
- Treatment goals achieved or not progressing
|
||||
- Patient request or preference change
|
||||
- Hospitalization or emergency department visit
|
||||
- Medication changes or adverse events
|
||||
|
||||
### Documentation of Changes
|
||||
- Date of revision
|
||||
- Reason for update
|
||||
- What changed (goals, interventions, timeline)
|
||||
- Provider signature
|
||||
- Maintain prior versions for record
|
||||
|
||||
## Specialty-Specific Requirements
|
||||
|
||||
### Diabetes Management Plans
|
||||
- HbA1c targets individualized
|
||||
- Complication screening schedule (eyes, feet, kidneys)
|
||||
- Self-monitoring blood glucose frequency
|
||||
- Hypoglycemia recognition and treatment
|
||||
- Sick day management
|
||||
|
||||
### Heart Failure Plans
|
||||
- GDMT (guideline-directed medical therapy) checklist
|
||||
- Volume management (daily weights, fluid/sodium restriction)
|
||||
- NYHA functional class documentation
|
||||
- Device therapy consideration
|
||||
- Hospitalization triggers
|
||||
|
||||
### Mental Health Treatment Plans
|
||||
- DSM-5 diagnostic criteria met
|
||||
- Suicide/violence risk assessment
|
||||
- Safety planning
|
||||
- Psychotherapy modality and frequency
|
||||
- Medication trials and responses
|
||||
- Functional goals (return to work, relationships)
|
||||
|
||||
### Chronic Pain Plans
|
||||
- Comprehensive pain assessment
|
||||
- Functional goals (not just pain scores)
|
||||
- Multimodal analgesia
|
||||
- Opioid risk assessment if prescribing
|
||||
- Physical and psychological interventions
|
||||
- Activity modification and pacing
|
||||
|
||||
## Cultural Competence and Health Equity
|
||||
|
||||
### Culturally Appropriate Care
|
||||
- Recognize cultural health beliefs and practices
|
||||
- Address language barriers (interpreter services)
|
||||
- Respect religious and cultural preferences in treatment
|
||||
- Consider social determinants of health (housing, food security, transportation)
|
||||
- Avoid assumptions based on stereotypes
|
||||
|
||||
### Health Literacy
|
||||
- Assess patient understanding (teach-back method)
|
||||
- Use plain language, avoid medical jargon
|
||||
- Visual aids and written materials at appropriate reading level
|
||||
- Tailor education to patient's learning style
|
||||
|
||||
### Addressing Disparities
|
||||
- Screen for social needs and barriers
|
||||
- Connect to community resources
|
||||
- Culturally tailored interventions when evidence supports
|
||||
- Track outcomes by demographic groups, address disparities
|
||||
|
||||
## References and Guidelines
|
||||
|
||||
### General Standards
|
||||
- Joint Commission Standards Manual
|
||||
- CMS Conditions of Participation
|
||||
- State medical board documentation requirements
|
||||
|
||||
### Specialty Guidelines
|
||||
- American College of Physicians (ACP)
|
||||
- American Academy of Family Physicians (AAFP)
|
||||
- American Psychiatric Association (APA)
|
||||
- American Physical Therapy Association (APTA)
|
||||
- Disease-specific societies (ADA, AHA, ACC, etc.)
|
||||
|
||||
### Regulatory
|
||||
- HIPAA Privacy Rule (45 CFR Part 160, 164)
|
||||
- 42 CFR Part 2 (Substance Use Disorder Confidentiality)
|
||||
- 21 CFR Part 11 (Electronic Records, applicable for research/trials)
|
||||
- State scope of practice laws
|
||||
|
||||
---
|
||||
|
||||
**Document Version**: 1.0
|
||||
**Last Updated**: January 2025
|
||||
**Next Review**: January 2026
|
||||
|
||||
318
skills/treatment-plans/scripts/check_completeness.py
Normal file
318
skills/treatment-plans/scripts/check_completeness.py
Normal file
@@ -0,0 +1,318 @@
|
||||
#!/usr/bin/env python3
|
||||
"""
|
||||
Check Treatment Plan Completeness
|
||||
Validates that all required sections are present in a treatment plan.
|
||||
"""
|
||||
|
||||
import sys
|
||||
import re
|
||||
import argparse
|
||||
from pathlib import Path
|
||||
from typing import List, Tuple
|
||||
|
||||
# Required sections for all treatment plans
|
||||
REQUIRED_SECTIONS = [
|
||||
r'\\section\*\{.*Patient Information',
|
||||
r'\\section\*\{.*Diagnosis.*Assessment',
|
||||
r'\\section\*\{.*Goals',
|
||||
r'\\section\*\{.*Interventions',
|
||||
r'\\section\*\{.*Timeline.*Schedule',
|
||||
r'\\section\*\{.*Monitoring',
|
||||
r'\\section\*\{.*Outcomes',
|
||||
r'\\section\*\{.*Follow[- ]?up',
|
||||
r'\\section\*\{.*Education',
|
||||
r'\\section\*\{.*Risk.*Safety',
|
||||
]
|
||||
|
||||
# Section descriptions for user-friendly output
|
||||
SECTION_DESCRIPTIONS = {
|
||||
0: 'Patient Information (de-identified)',
|
||||
1: 'Diagnosis and Assessment',
|
||||
2: 'Treatment Goals (SMART format)',
|
||||
3: 'Interventions (pharmacological, non-pharmacological, procedural)',
|
||||
4: 'Timeline and Schedule',
|
||||
5: 'Monitoring Parameters',
|
||||
6: 'Expected Outcomes',
|
||||
7: 'Follow-up Plan',
|
||||
8: 'Patient Education',
|
||||
9: 'Risk Mitigation and Safety'
|
||||
}
|
||||
|
||||
|
||||
def read_file(filepath: Path) -> str:
|
||||
"""Read and return file contents."""
|
||||
try:
|
||||
with open(filepath, 'r', encoding='utf-8') as f:
|
||||
return f.read()
|
||||
except FileNotFoundError:
|
||||
print(f"Error: File not found: {filepath}", file=sys.stderr)
|
||||
sys.exit(1)
|
||||
except Exception as e:
|
||||
print(f"Error reading file: {e}", file=sys.stderr)
|
||||
sys.exit(1)
|
||||
|
||||
|
||||
def check_sections(content: str) -> Tuple[List[bool], List[str]]:
|
||||
"""
|
||||
Check which required sections are present.
|
||||
Returns tuple of (checklist, missing_sections).
|
||||
"""
|
||||
checklist = []
|
||||
missing = []
|
||||
|
||||
for i, pattern in enumerate(REQUIRED_SECTIONS):
|
||||
if re.search(pattern, content, re.IGNORECASE):
|
||||
checklist.append(True)
|
||||
else:
|
||||
checklist.append(False)
|
||||
missing.append(SECTION_DESCRIPTIONS[i])
|
||||
|
||||
return checklist, missing
|
||||
|
||||
|
||||
def check_smart_goals(content: str) -> Tuple[bool, List[str]]:
|
||||
"""
|
||||
Check if SMART goal criteria are mentioned.
|
||||
Returns (has_smart, missing_criteria).
|
||||
"""
|
||||
smart_criteria = {
|
||||
'Specific': r'\bspecific\b',
|
||||
'Measurable': r'\bmeasurable\b',
|
||||
'Achievable': r'\bachievable\b',
|
||||
'Relevant': r'\brelevant\b',
|
||||
'Time-bound': r'\btime[- ]?bound\b'
|
||||
}
|
||||
|
||||
missing = []
|
||||
for criterion, pattern in smart_criteria.items():
|
||||
if not re.search(pattern, content, re.IGNORECASE):
|
||||
missing.append(criterion)
|
||||
|
||||
has_smart = len(missing) == 0
|
||||
return has_smart, missing
|
||||
|
||||
|
||||
def check_hipaa_notice(content: str) -> bool:
|
||||
"""Check if HIPAA de-identification notice is present."""
|
||||
pattern = r'HIPAA|de-identif|protected health information|PHI'
|
||||
return bool(re.search(pattern, content, re.IGNORECASE))
|
||||
|
||||
|
||||
def check_provider_signature(content: str) -> bool:
|
||||
"""Check if provider signature section is present."""
|
||||
pattern = r'\\section\*\{.*Signature|Provider Signature|Signature'
|
||||
return bool(re.search(pattern, content, re.IGNORECASE))
|
||||
|
||||
|
||||
def check_placeholders_remaining(content: str) -> Tuple[int, List[str]]:
|
||||
"""
|
||||
Check for uncustomized placeholders [like this].
|
||||
Returns (count, sample_placeholders).
|
||||
"""
|
||||
placeholders = re.findall(r'\[([^\]]+)\]', content)
|
||||
|
||||
# Filter out LaTeX commands and references
|
||||
filtered = []
|
||||
for p in placeholders:
|
||||
# Skip if it's a LaTeX command, number, or citation
|
||||
if not (p.startswith('\\') or p.isdigit() or 'cite' in p.lower() or 'ref' in p.lower()):
|
||||
filtered.append(p)
|
||||
|
||||
count = len(filtered)
|
||||
samples = filtered[:5] # Return up to 5 examples
|
||||
|
||||
return count, samples
|
||||
|
||||
|
||||
def display_results(filepath: Path, checklist: List[bool], missing: List[str],
|
||||
smart_complete: bool, smart_missing: List[str],
|
||||
has_hipaa: bool, has_signature: bool,
|
||||
placeholder_count: int, placeholder_samples: List[str]):
|
||||
"""Display completeness check results."""
|
||||
|
||||
total_sections = len(REQUIRED_SECTIONS)
|
||||
present_count = sum(checklist)
|
||||
completeness_pct = (present_count / total_sections) * 100
|
||||
|
||||
print("\n" + "="*70)
|
||||
print("TREATMENT PLAN COMPLETENESS CHECK")
|
||||
print("="*70)
|
||||
print(f"\nFile: {filepath}")
|
||||
print(f"File size: {filepath.stat().st_size:,} bytes")
|
||||
|
||||
# Overall completeness
|
||||
print("\n" + "-"*70)
|
||||
print("OVERALL COMPLETENESS")
|
||||
print("-"*70)
|
||||
print(f"Required sections present: {present_count}/{total_sections} ({completeness_pct:.0f}%)")
|
||||
|
||||
if completeness_pct == 100:
|
||||
print("✓ All required sections present")
|
||||
else:
|
||||
print(f"✗ {len(missing)} section(s) missing")
|
||||
|
||||
# Section details
|
||||
print("\n" + "-"*70)
|
||||
print("SECTION CHECKLIST")
|
||||
print("-"*70)
|
||||
|
||||
for i, (present, desc) in enumerate(zip(checklist, SECTION_DESCRIPTIONS.values())):
|
||||
status = "✓" if present else "✗"
|
||||
print(f"{status} {desc}")
|
||||
|
||||
# Missing sections
|
||||
if missing:
|
||||
print("\n" + "-"*70)
|
||||
print("MISSING SECTIONS")
|
||||
print("-"*70)
|
||||
for section in missing:
|
||||
print(f" • {section}")
|
||||
|
||||
# SMART goals
|
||||
print("\n" + "-"*70)
|
||||
print("SMART GOALS CHECK")
|
||||
print("-"*70)
|
||||
|
||||
if smart_complete:
|
||||
print("✓ All SMART criteria mentioned in document")
|
||||
else:
|
||||
print(f"✗ {len(smart_missing)} SMART criterion/criteria not found:")
|
||||
for criterion in smart_missing:
|
||||
print(f" • {criterion}")
|
||||
print("\nNote: Goals should be Specific, Measurable, Achievable, Relevant, Time-bound")
|
||||
|
||||
# HIPAA notice
|
||||
print("\n" + "-"*70)
|
||||
print("PRIVACY AND COMPLIANCE")
|
||||
print("-"*70)
|
||||
|
||||
if has_hipaa:
|
||||
print("✓ HIPAA/de-identification notice present")
|
||||
else:
|
||||
print("✗ HIPAA de-identification notice not found")
|
||||
print(" Recommendation: Include HIPAA Safe Harbor de-identification guidance")
|
||||
|
||||
if has_signature:
|
||||
print("✓ Provider signature section present")
|
||||
else:
|
||||
print("✗ Provider signature section not found")
|
||||
|
||||
# Placeholders
|
||||
print("\n" + "-"*70)
|
||||
print("CUSTOMIZATION STATUS")
|
||||
print("-"*70)
|
||||
|
||||
if placeholder_count == 0:
|
||||
print("✓ No uncustomized placeholders detected")
|
||||
else:
|
||||
print(f"⚠ {placeholder_count} placeholder(s) may need customization")
|
||||
print("\nExamples:")
|
||||
for sample in placeholder_samples:
|
||||
print(f" • [{sample}]")
|
||||
print("\nRecommendation: Replace all [bracketed placeholders] with patient-specific information")
|
||||
|
||||
# Summary
|
||||
print("\n" + "="*70)
|
||||
print("SUMMARY")
|
||||
print("="*70)
|
||||
|
||||
# Calculate overall score
|
||||
score_components = [
|
||||
completeness_pct / 100, # Section completeness (0-1)
|
||||
1.0 if smart_complete else 0.6, # SMART goals (full or partial credit)
|
||||
1.0 if has_hipaa else 0.0, # HIPAA notice (binary)
|
||||
1.0 if has_signature else 0.0, # Signature (binary)
|
||||
1.0 if placeholder_count == 0 else 0.5 # Customization (full or partial)
|
||||
]
|
||||
|
||||
overall_score = (sum(score_components) / len(score_components)) * 100
|
||||
|
||||
print(f"\nOverall completeness score: {overall_score:.0f}%")
|
||||
|
||||
if overall_score >= 90:
|
||||
print("Status: ✓ EXCELLENT - Treatment plan is comprehensive")
|
||||
elif overall_score >= 75:
|
||||
print("Status: ✓ GOOD - Minor improvements needed")
|
||||
elif overall_score >= 60:
|
||||
print("Status: ⚠ FAIR - Several sections need attention")
|
||||
else:
|
||||
print("Status: ✗ INCOMPLETE - Significant work needed")
|
||||
|
||||
print("\n" + "="*70)
|
||||
|
||||
# Return exit code based on completeness
|
||||
return 0 if completeness_pct >= 80 else 1
|
||||
|
||||
|
||||
def main():
|
||||
parser = argparse.ArgumentParser(
|
||||
description='Check treatment plan completeness',
|
||||
formatter_class=argparse.RawDescriptionHelpFormatter,
|
||||
epilog="""
|
||||
Examples:
|
||||
# Check a treatment plan file
|
||||
python check_completeness.py my_treatment_plan.tex
|
||||
|
||||
# Check and exit with error code if incomplete (for CI/CD)
|
||||
python check_completeness.py plan.tex && echo "Complete"
|
||||
|
||||
This script checks for:
|
||||
- All required sections (10 core sections)
|
||||
- SMART goal criteria
|
||||
- HIPAA de-identification notice
|
||||
- Provider signature section
|
||||
- Uncustomized placeholders
|
||||
|
||||
Exit codes:
|
||||
0 - All required sections present (≥80% complete)
|
||||
1 - Missing required sections (<80% complete)
|
||||
2 - File error or invalid arguments
|
||||
"""
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'file',
|
||||
type=Path,
|
||||
help='Treatment plan file to check (.tex format)'
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'-v', '--verbose',
|
||||
action='store_true',
|
||||
help='Show detailed output'
|
||||
)
|
||||
|
||||
args = parser.parse_args()
|
||||
|
||||
# Check file exists and is .tex
|
||||
if not args.file.exists():
|
||||
print(f"Error: File not found: {args.file}", file=sys.stderr)
|
||||
sys.exit(2)
|
||||
|
||||
if args.file.suffix.lower() not in ['.tex', '.txt']:
|
||||
print(f"Warning: Expected .tex file, got {args.file.suffix}", file=sys.stderr)
|
||||
|
||||
# Read file
|
||||
content = read_file(args.file)
|
||||
|
||||
# Perform checks
|
||||
checklist, missing = check_sections(content)
|
||||
smart_complete, smart_missing = check_smart_goals(content)
|
||||
has_hipaa = check_hipaa_notice(content)
|
||||
has_signature = check_provider_signature(content)
|
||||
placeholder_count, placeholder_samples = check_placeholders_remaining(content)
|
||||
|
||||
# Display results
|
||||
exit_code = display_results(
|
||||
args.file, checklist, missing,
|
||||
smart_complete, smart_missing,
|
||||
has_hipaa, has_signature,
|
||||
placeholder_count, placeholder_samples
|
||||
)
|
||||
|
||||
sys.exit(exit_code)
|
||||
|
||||
|
||||
if __name__ == '__main__':
|
||||
main()
|
||||
|
||||
244
skills/treatment-plans/scripts/generate_template.py
Normal file
244
skills/treatment-plans/scripts/generate_template.py
Normal file
@@ -0,0 +1,244 @@
|
||||
#!/usr/bin/env python3
|
||||
"""
|
||||
Generate Treatment Plan Template
|
||||
Interactive script to select and generate treatment plan templates.
|
||||
"""
|
||||
|
||||
import os
|
||||
import sys
|
||||
import shutil
|
||||
import argparse
|
||||
from pathlib import Path
|
||||
from datetime import datetime
|
||||
|
||||
# Template types and descriptions
|
||||
TEMPLATES = {
|
||||
'general_medical': {
|
||||
'name': 'General Medical Treatment Plan',
|
||||
'file': 'general_medical_treatment_plan.tex',
|
||||
'description': 'For primary care and chronic disease management (diabetes, hypertension, etc.)'
|
||||
},
|
||||
'rehabilitation': {
|
||||
'name': 'Rehabilitation Treatment Plan',
|
||||
'file': 'rehabilitation_treatment_plan.tex',
|
||||
'description': 'For physical therapy, occupational therapy, and rehabilitation services'
|
||||
},
|
||||
'mental_health': {
|
||||
'name': 'Mental Health Treatment Plan',
|
||||
'file': 'mental_health_treatment_plan.tex',
|
||||
'description': 'For psychiatric and behavioral health treatment'
|
||||
},
|
||||
'chronic_disease': {
|
||||
'name': 'Chronic Disease Management Plan',
|
||||
'file': 'chronic_disease_management_plan.tex',
|
||||
'description': 'For complex multimorbidity and long-term care coordination'
|
||||
},
|
||||
'perioperative': {
|
||||
'name': 'Perioperative Care Plan',
|
||||
'file': 'perioperative_care_plan.tex',
|
||||
'description': 'For surgical and procedural patient management'
|
||||
},
|
||||
'pain_management': {
|
||||
'name': 'Pain Management Plan',
|
||||
'file': 'pain_management_plan.tex',
|
||||
'description': 'For acute and chronic pain treatment (multimodal approach)'
|
||||
}
|
||||
}
|
||||
|
||||
|
||||
def get_templates_dir():
|
||||
"""Get the path to the templates directory."""
|
||||
# Assume script is in .claude/skills/treatment-plans/scripts/
|
||||
script_dir = Path(__file__).parent
|
||||
templates_dir = script_dir.parent / 'assets'
|
||||
return templates_dir
|
||||
|
||||
|
||||
def list_templates():
|
||||
"""Display available templates."""
|
||||
print("\n" + "="*70)
|
||||
print("AVAILABLE TREATMENT PLAN TEMPLATES")
|
||||
print("="*70)
|
||||
|
||||
for i, (key, info) in enumerate(TEMPLATES.items(), 1):
|
||||
print(f"\n{i}. {info['name']}")
|
||||
print(f" Type: {key}")
|
||||
print(f" File: {info['file']}")
|
||||
print(f" Description: {info['description']}")
|
||||
|
||||
print("\n" + "="*70)
|
||||
|
||||
|
||||
def interactive_selection():
|
||||
"""Interactive template selection."""
|
||||
list_templates()
|
||||
|
||||
while True:
|
||||
try:
|
||||
choice = input("\nSelect template number (1-6) or 'q' to quit: ").strip().lower()
|
||||
|
||||
if choice == 'q':
|
||||
print("Exiting...")
|
||||
sys.exit(0)
|
||||
|
||||
choice_num = int(choice)
|
||||
|
||||
if 1 <= choice_num <= len(TEMPLATES):
|
||||
template_key = list(TEMPLATES.keys())[choice_num - 1]
|
||||
return template_key
|
||||
else:
|
||||
print(f"Please enter a number between 1 and {len(TEMPLATES)}.")
|
||||
except ValueError:
|
||||
print("Invalid input. Please enter a number or 'q' to quit.")
|
||||
|
||||
|
||||
def get_output_filename(template_key, custom_name=None):
|
||||
"""Generate output filename."""
|
||||
if custom_name:
|
||||
# Ensure .tex extension
|
||||
if not custom_name.endswith('.tex'):
|
||||
custom_name += '.tex'
|
||||
return custom_name
|
||||
|
||||
# Default: template_key_YYYYMMDD.tex
|
||||
timestamp = datetime.now().strftime('%Y%m%d')
|
||||
return f"{template_key}_plan_{timestamp}.tex"
|
||||
|
||||
|
||||
def copy_template(template_key, output_path):
|
||||
"""Copy template to output location."""
|
||||
templates_dir = get_templates_dir()
|
||||
template_file = TEMPLATES[template_key]['file']
|
||||
source_path = templates_dir / template_file
|
||||
|
||||
if not source_path.exists():
|
||||
raise FileNotFoundError(f"Template not found: {source_path}")
|
||||
|
||||
# Create output directory if it doesn't exist
|
||||
output_path = Path(output_path)
|
||||
output_path.parent.mkdir(parents=True, exist_ok=True)
|
||||
|
||||
# Copy template
|
||||
shutil.copy2(source_path, output_path)
|
||||
|
||||
return output_path
|
||||
|
||||
|
||||
def display_success(output_path, template_key):
|
||||
"""Display success message with next steps."""
|
||||
template_info = TEMPLATES[template_key]
|
||||
|
||||
print("\n" + "="*70)
|
||||
print("✓ TEMPLATE GENERATED SUCCESSFULLY")
|
||||
print("="*70)
|
||||
print(f"\nTemplate: {template_info['name']}")
|
||||
print(f"Output file: {output_path}")
|
||||
print(f"File size: {os.path.getsize(output_path):,} bytes")
|
||||
|
||||
print("\n" + "-"*70)
|
||||
print("NEXT STEPS:")
|
||||
print("-"*70)
|
||||
|
||||
print("\n1. CUSTOMIZE THE TEMPLATE:")
|
||||
print(" - Open the .tex file in your LaTeX editor")
|
||||
print(" - Replace all [bracketed placeholders] with patient-specific information")
|
||||
print(" - Remove or modify sections as appropriate for your patient")
|
||||
|
||||
print("\n2. COMPILE TO PDF:")
|
||||
print(f" $ pdflatex {output_path.name}")
|
||||
|
||||
print("\n3. VALIDATE (optional):")
|
||||
print(f" $ python check_completeness.py {output_path.name}")
|
||||
print(f" $ python validate_treatment_plan.py {output_path.name}")
|
||||
|
||||
print("\n4. DE-IDENTIFY BEFORE SHARING:")
|
||||
print(" - Remove all HIPAA identifiers (18 identifiers)")
|
||||
print(" - See regulatory_compliance.md reference for details")
|
||||
|
||||
print("\n" + "="*70)
|
||||
|
||||
|
||||
def main():
|
||||
parser = argparse.ArgumentParser(
|
||||
description='Generate treatment plan template',
|
||||
formatter_class=argparse.RawDescriptionHelpFormatter,
|
||||
epilog="""
|
||||
Examples:
|
||||
# Interactive mode (recommended for first-time users)
|
||||
python generate_template.py
|
||||
|
||||
# Direct generation with type specification
|
||||
python generate_template.py --type general_medical --output diabetes_plan.tex
|
||||
|
||||
# Generate with default filename
|
||||
python generate_template.py --type mental_health
|
||||
|
||||
# List available templates
|
||||
python generate_template.py --list
|
||||
|
||||
Available template types:
|
||||
general_medical, rehabilitation, mental_health, chronic_disease,
|
||||
perioperative, pain_management
|
||||
"""
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--type',
|
||||
choices=list(TEMPLATES.keys()),
|
||||
help='Template type to generate'
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--output',
|
||||
help='Output filename (default: auto-generated with timestamp)'
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--list',
|
||||
action='store_true',
|
||||
help='List available templates and exit'
|
||||
)
|
||||
|
||||
args = parser.parse_args()
|
||||
|
||||
# List templates and exit
|
||||
if args.list:
|
||||
list_templates()
|
||||
return
|
||||
|
||||
# Determine template type
|
||||
if args.type:
|
||||
template_key = args.type
|
||||
print(f"\nGenerating template: {TEMPLATES[template_key]['name']}")
|
||||
else:
|
||||
# Interactive mode
|
||||
template_key = interactive_selection()
|
||||
|
||||
# Determine output filename
|
||||
if args.output:
|
||||
output_filename = args.output
|
||||
else:
|
||||
output_filename = get_output_filename(template_key)
|
||||
|
||||
# Default output to current directory
|
||||
output_path = Path.cwd() / output_filename
|
||||
|
||||
# Confirm overwrite if file exists
|
||||
if output_path.exists():
|
||||
response = input(f"\nFile {output_filename} already exists. Overwrite? (y/n): ").strip().lower()
|
||||
if response != 'y':
|
||||
print("Cancelled.")
|
||||
return
|
||||
|
||||
# Copy template
|
||||
try:
|
||||
output_path = copy_template(template_key, output_path)
|
||||
display_success(output_path, template_key)
|
||||
except Exception as e:
|
||||
print(f"\n✗ ERROR: {e}", file=sys.stderr)
|
||||
sys.exit(1)
|
||||
|
||||
|
||||
if __name__ == '__main__':
|
||||
main()
|
||||
|
||||
369
skills/treatment-plans/scripts/timeline_generator.py
Normal file
369
skills/treatment-plans/scripts/timeline_generator.py
Normal file
@@ -0,0 +1,369 @@
|
||||
#!/usr/bin/env python3
|
||||
"""
|
||||
Treatment Timeline Generator
|
||||
Generates visual treatment timelines from treatment plan files.
|
||||
"""
|
||||
|
||||
import sys
|
||||
import re
|
||||
import argparse
|
||||
from pathlib import Path
|
||||
from datetime import datetime, timedelta
|
||||
from typing import List, Dict, Tuple
|
||||
|
||||
# Try to import matplotlib, but make it optional
|
||||
try:
|
||||
import matplotlib.pyplot as plt
|
||||
import matplotlib.dates as mdates
|
||||
from matplotlib.patches import Rectangle
|
||||
HAS_MATPLOTLIB = True
|
||||
except ImportError:
|
||||
HAS_MATPLOTLIB = False
|
||||
|
||||
|
||||
def extract_timeline_info(content: str) -> Dict[str, List[Tuple[str, str]]]:
|
||||
"""
|
||||
Extract timeline and schedule information from treatment plan.
|
||||
Returns dict with phases, appointments, milestones.
|
||||
"""
|
||||
timeline_data = {
|
||||
'phases': [],
|
||||
'appointments': [],
|
||||
'milestones': []
|
||||
}
|
||||
|
||||
# Extract treatment phases
|
||||
# Look for patterns like "Week 1-4: Description" or "Months 1-3: Description"
|
||||
phase_patterns = [
|
||||
r'(Week[s]?\s*\d+[-–]\d+|Month[s]?\s*\d+[-–]\d+)[:\s]+([^\n]+)',
|
||||
r'(POD\s*\d+[-–]\d+)[:\s]+([^\n]+)',
|
||||
r'(\d+[-–]\d+\s*week[s]?)[:\s]+([^\n]+)'
|
||||
]
|
||||
|
||||
for pattern in phase_patterns:
|
||||
matches = re.findall(pattern, content, re.IGNORECASE)
|
||||
for timeframe, description in matches:
|
||||
timeline_data['phases'].append((timeframe.strip(), description.strip()))
|
||||
|
||||
# Extract appointments
|
||||
# Look for patterns like "Week 2: Visit" or "Month 3: Follow-up"
|
||||
apt_patterns = [
|
||||
r'(Week\s*\d+|Month\s*\d+|POD\s*\d+)[:\s]+(Visit|Appointment|Follow-up|Check-up|Consultation)([^\n]*)',
|
||||
r'(Every\s+\d+\s+\w+)[:\s]+(Visit|Appointment|therapy|session)([^\n]*)'
|
||||
]
|
||||
|
||||
for pattern in apt_patterns:
|
||||
matches = re.findall(pattern, content, re.IGNORECASE)
|
||||
for timeframe, visit_type, details in matches:
|
||||
timeline_data['appointments'].append((timeframe.strip(), f"{visit_type}{details}".strip()))
|
||||
|
||||
# Extract milestones/assessments
|
||||
# Look for "reassessment", "goal evaluation", "milestone" mentions
|
||||
milestone_patterns = [
|
||||
r'(Week\s*\d+|Month\s*\d+)[:\s]+(reassess|evaluation|assessment|milestone)([^\n]*)',
|
||||
r'(\w+\s*\d+)[:\s]+(HbA1c|labs?|imaging|test)([^\n]*)'
|
||||
]
|
||||
|
||||
for pattern in milestone_patterns:
|
||||
matches = re.findall(pattern, content, re.IGNORECASE)
|
||||
for timeframe, event_type, details in matches:
|
||||
timeline_data['milestones'].append((timeframe.strip(), f"{event_type}{details}".strip()))
|
||||
|
||||
return timeline_data
|
||||
|
||||
|
||||
def parse_timeframe_to_days(timeframe: str) -> Tuple[int, int]:
|
||||
"""
|
||||
Parse timeframe string to start and end days.
|
||||
Examples: "Week 1-4" -> (0, 28), "Month 3" -> (60, 90)
|
||||
"""
|
||||
timeframe = timeframe.lower()
|
||||
|
||||
# Week patterns
|
||||
if 'week' in timeframe:
|
||||
weeks = re.findall(r'\d+', timeframe)
|
||||
if len(weeks) == 2:
|
||||
start_week = int(weeks[0])
|
||||
end_week = int(weeks[1])
|
||||
return ((start_week - 1) * 7, end_week * 7)
|
||||
elif len(weeks) == 1:
|
||||
week = int(weeks[0])
|
||||
return ((week - 1) * 7, week * 7)
|
||||
|
||||
# Month patterns
|
||||
if 'month' in timeframe:
|
||||
months = re.findall(r'\d+', timeframe)
|
||||
if len(months) == 2:
|
||||
start_month = int(months[0])
|
||||
end_month = int(months[1])
|
||||
return ((start_month - 1) * 30, end_month * 30)
|
||||
elif len(months) == 1:
|
||||
month = int(months[0])
|
||||
return ((month - 1) * 30, month * 30)
|
||||
|
||||
# POD (post-operative day) patterns
|
||||
if 'pod' in timeframe:
|
||||
days = re.findall(r'\d+', timeframe)
|
||||
if len(days) == 2:
|
||||
return (int(days[0]), int(days[1]))
|
||||
elif len(days) == 1:
|
||||
day = int(days[0])
|
||||
return (day, day + 1)
|
||||
|
||||
# Default fallback
|
||||
return (0, 7)
|
||||
|
||||
|
||||
def create_text_timeline(timeline_data: Dict, output_file: Path = None):
|
||||
"""Create a text-based timeline representation."""
|
||||
|
||||
lines = []
|
||||
lines.append("="*70)
|
||||
lines.append("TREATMENT TIMELINE")
|
||||
lines.append("="*70)
|
||||
|
||||
# Treatment phases
|
||||
if timeline_data['phases']:
|
||||
lines.append("\nTREATMENT PHASES:")
|
||||
lines.append("-"*70)
|
||||
for timeframe, description in timeline_data['phases']:
|
||||
lines.append(f"{timeframe:20s} | {description}")
|
||||
|
||||
# Appointments
|
||||
if timeline_data['appointments']:
|
||||
lines.append("\nSCHEDULED APPOINTMENTS:")
|
||||
lines.append("-"*70)
|
||||
for timeframe, details in timeline_data['appointments']:
|
||||
lines.append(f"{timeframe:20s} | {details}")
|
||||
|
||||
# Milestones
|
||||
if timeline_data['milestones']:
|
||||
lines.append("\nMILESTONES & ASSESSMENTS:")
|
||||
lines.append("-"*70)
|
||||
for timeframe, event in timeline_data['milestones']:
|
||||
lines.append(f"{timeframe:20s} | {event}")
|
||||
|
||||
lines.append("\n" + "="*70)
|
||||
|
||||
# Output
|
||||
output_text = "\n".join(lines)
|
||||
|
||||
if output_file:
|
||||
with open(output_file, 'w') as f:
|
||||
f.write(output_text)
|
||||
print(f"\nText timeline saved to: {output_file}")
|
||||
else:
|
||||
print(output_text)
|
||||
|
||||
return output_text
|
||||
|
||||
|
||||
def create_visual_timeline(timeline_data: Dict, output_file: Path, start_date: str = None):
|
||||
"""Create a visual Gantt-chart style timeline (requires matplotlib)."""
|
||||
|
||||
if not HAS_MATPLOTLIB:
|
||||
print("Error: matplotlib not installed. Install with: pip install matplotlib", file=sys.stderr)
|
||||
print("Generating text timeline instead...", file=sys.stderr)
|
||||
text_output = output_file.with_suffix('.txt')
|
||||
create_text_timeline(timeline_data, text_output)
|
||||
return
|
||||
|
||||
# Parse start date
|
||||
if start_date:
|
||||
try:
|
||||
start = datetime.strptime(start_date, '%Y-%m-%d')
|
||||
except ValueError:
|
||||
print(f"Invalid date format: {start_date}. Using today.", file=sys.stderr)
|
||||
start = datetime.now()
|
||||
else:
|
||||
start = datetime.now()
|
||||
|
||||
# Prepare data for plotting
|
||||
phases = []
|
||||
for timeframe, description in timeline_data['phases']:
|
||||
start_day, end_day = parse_timeframe_to_days(timeframe)
|
||||
phases.append({
|
||||
'name': f"{timeframe}: {description[:40]}",
|
||||
'start': start + timedelta(days=start_day),
|
||||
'end': start + timedelta(days=end_day),
|
||||
'type': 'phase'
|
||||
})
|
||||
|
||||
# Add appointments as events
|
||||
events = []
|
||||
for timeframe, details in timeline_data['appointments']:
|
||||
start_day, _ = parse_timeframe_to_days(timeframe)
|
||||
events.append({
|
||||
'name': f"{timeframe}: {details[:40]}",
|
||||
'date': start + timedelta(days=start_day),
|
||||
'type': 'appointment'
|
||||
})
|
||||
|
||||
# Add milestones
|
||||
for timeframe, event in timeline_data['milestones']:
|
||||
start_day, _ = parse_timeframe_to_days(timeframe)
|
||||
events.append({
|
||||
'name': f"{timeframe}: {event[:40]}",
|
||||
'date': start + timedelta(days=start_day),
|
||||
'type': 'milestone'
|
||||
})
|
||||
|
||||
# Create figure
|
||||
fig, ax = plt.subplots(figsize=(12, 8))
|
||||
|
||||
# Plot phases as horizontal bars
|
||||
y_position = len(phases) + len(events)
|
||||
|
||||
for i, phase in enumerate(phases):
|
||||
duration = (phase['end'] - phase['start']).days
|
||||
ax.barh(y_position - i, duration, left=mdates.date2num(phase['start']),
|
||||
height=0.6, color='steelblue', alpha=0.7, edgecolor='black')
|
||||
ax.text(mdates.date2num(phase['start']) + duration/2, y_position - i,
|
||||
phase['name'], va='center', ha='center', fontsize=9, color='white', weight='bold')
|
||||
|
||||
# Plot events as markers
|
||||
event_y = y_position - len(phases) - 1
|
||||
|
||||
for i, event in enumerate(events):
|
||||
marker = 'o' if event['type'] == 'appointment' else 's'
|
||||
color = 'green' if event['type'] == 'appointment' else 'orange'
|
||||
ax.plot(mdates.date2num(event['date']), event_y - i, marker=marker,
|
||||
markersize=10, color=color, markeredgecolor='black')
|
||||
ax.text(mdates.date2num(event['date']) + 2, event_y - i, event['name'],
|
||||
va='center', ha='left', fontsize=8)
|
||||
|
||||
# Format x-axis as dates
|
||||
ax.xaxis.set_major_formatter(mdates.DateFormatter('%b %Y'))
|
||||
ax.xaxis.set_major_locator(mdates.MonthLocator())
|
||||
plt.xticks(rotation=45, ha='right')
|
||||
|
||||
# Labels and title
|
||||
ax.set_xlabel('Date', fontsize=12, weight='bold')
|
||||
ax.set_title('Treatment Plan Timeline', fontsize=14, weight='bold', pad=20)
|
||||
ax.set_yticks([])
|
||||
ax.grid(axis='x', alpha=0.3, linestyle='--')
|
||||
|
||||
# Legend
|
||||
from matplotlib.lines import Line2D
|
||||
legend_elements = [
|
||||
Rectangle((0, 0), 1, 1, fc='steelblue', alpha=0.7, edgecolor='black', label='Treatment Phase'),
|
||||
Line2D([0], [0], marker='o', color='w', markerfacecolor='green', markersize=10,
|
||||
markeredgecolor='black', label='Appointment'),
|
||||
Line2D([0], [0], marker='s', color='w', markerfacecolor='orange', markersize=10,
|
||||
markeredgecolor='black', label='Milestone/Assessment')
|
||||
]
|
||||
ax.legend(handles=legend_elements, loc='upper right', framealpha=0.9)
|
||||
|
||||
plt.tight_layout()
|
||||
|
||||
# Save
|
||||
plt.savefig(output_file, dpi=300, bbox_inches='tight')
|
||||
print(f"\nVisual timeline saved to: {output_file}")
|
||||
|
||||
# Close plot
|
||||
plt.close()
|
||||
|
||||
|
||||
def main():
|
||||
parser = argparse.ArgumentParser(
|
||||
description='Generate treatment timeline visualization',
|
||||
formatter_class=argparse.RawDescriptionHelpFormatter,
|
||||
epilog="""
|
||||
Examples:
|
||||
# Generate text timeline
|
||||
python timeline_generator.py --plan my_plan.tex
|
||||
|
||||
# Generate visual timeline (requires matplotlib)
|
||||
python timeline_generator.py --plan my_plan.tex --output timeline.png --visual
|
||||
|
||||
# Specify start date for visual timeline
|
||||
python timeline_generator.py --plan my_plan.tex --output timeline.pdf --visual --start 2025-02-01
|
||||
|
||||
Output formats:
|
||||
Text: .txt
|
||||
Visual: .png, .pdf, .svg (requires matplotlib)
|
||||
|
||||
Note: Visual timeline generation requires matplotlib.
|
||||
Install with: pip install matplotlib
|
||||
"""
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--plan',
|
||||
type=Path,
|
||||
required=True,
|
||||
help='Treatment plan file to analyze (.tex format)'
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--output',
|
||||
type=Path,
|
||||
help='Output file (default: timeline.txt or timeline.png if --visual)'
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--visual',
|
||||
action='store_true',
|
||||
help='Generate visual timeline (requires matplotlib)'
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'--start',
|
||||
help='Start date for timeline (YYYY-MM-DD format, default: today)'
|
||||
)
|
||||
|
||||
args = parser.parse_args()
|
||||
|
||||
# Check plan file exists
|
||||
if not args.plan.exists():
|
||||
print(f"Error: File not found: {args.plan}", file=sys.stderr)
|
||||
sys.exit(1)
|
||||
|
||||
# Read plan
|
||||
try:
|
||||
with open(args.plan, 'r', encoding='utf-8') as f:
|
||||
content = f.read()
|
||||
except Exception as e:
|
||||
print(f"Error reading file: {e}", file=sys.stderr)
|
||||
sys.exit(1)
|
||||
|
||||
# Extract timeline information
|
||||
print("Extracting timeline information from treatment plan...")
|
||||
timeline_data = extract_timeline_info(content)
|
||||
|
||||
# Check if any timeline info found
|
||||
total_items = (len(timeline_data['phases']) +
|
||||
len(timeline_data['appointments']) +
|
||||
len(timeline_data['milestones']))
|
||||
|
||||
if total_items == 0:
|
||||
print("\nWarning: No timeline information detected in treatment plan.", file=sys.stderr)
|
||||
print("The plan may not contain structured timeline/schedule sections.", file=sys.stderr)
|
||||
print("\nTip: Include sections with timeframes like:", file=sys.stderr)
|
||||
print(" - Week 1-4: Initial phase", file=sys.stderr)
|
||||
print(" - Month 3: Follow-up visit", file=sys.stderr)
|
||||
sys.exit(1)
|
||||
|
||||
print(f"Found {len(timeline_data['phases'])} phase(s), "
|
||||
f"{len(timeline_data['appointments'])} appointment(s), "
|
||||
f"{len(timeline_data['milestones'])} milestone(s)")
|
||||
|
||||
# Determine output file
|
||||
if not args.output:
|
||||
if args.visual:
|
||||
args.output = Path('timeline.png')
|
||||
else:
|
||||
args.output = Path('timeline.txt')
|
||||
|
||||
# Generate timeline
|
||||
if args.visual:
|
||||
create_visual_timeline(timeline_data, args.output, args.start)
|
||||
else:
|
||||
create_text_timeline(timeline_data, args.output)
|
||||
|
||||
print(f"\nTimeline generation complete!")
|
||||
|
||||
|
||||
if __name__ == '__main__':
|
||||
main()
|
||||
|
||||
367
skills/treatment-plans/scripts/validate_treatment_plan.py
Normal file
367
skills/treatment-plans/scripts/validate_treatment_plan.py
Normal file
@@ -0,0 +1,367 @@
|
||||
#!/usr/bin/env python3
|
||||
"""
|
||||
Validate Treatment Plan Quality
|
||||
Comprehensive validation of treatment plan content quality and compliance.
|
||||
"""
|
||||
|
||||
import sys
|
||||
import re
|
||||
import argparse
|
||||
from pathlib import Path
|
||||
from typing import Dict, List, Tuple
|
||||
|
||||
# Validation criteria and patterns
|
||||
VALIDATION_CHECKS = {
|
||||
'smart_goals': {
|
||||
'name': 'SMART Goals Criteria',
|
||||
'patterns': [
|
||||
(r'\bspecific\b', 'Specific criterion'),
|
||||
(r'\bmeasurable\b', 'Measurable criterion'),
|
||||
(r'\bachievable\b', 'Achievable criterion'),
|
||||
(r'\brelevant\b', 'Relevant criterion'),
|
||||
(r'\btime[- ]?bound\b', 'Time-bound criterion')
|
||||
]
|
||||
},
|
||||
'evidence_based': {
|
||||
'name': 'Evidence-Based Practice',
|
||||
'patterns': [
|
||||
(r'guideline|evidence|study|trial|research', 'Evidence/guideline references'),
|
||||
(r'\\cite\{|\\bibitem\{|\\bibliography\{', 'Citations present')
|
||||
]
|
||||
},
|
||||
'patient_centered': {
|
||||
'name': 'Patient-Centered Care',
|
||||
'patterns': [
|
||||
(r'patient.*preference|shared decision|patient.*value|patient.*priority', 'Patient preferences'),
|
||||
(r'quality of life|functional.*goal|patient.*goal', 'Functional/QoL goals')
|
||||
]
|
||||
},
|
||||
'safety': {
|
||||
'name': 'Safety and Risk Mitigation',
|
||||
'patterns': [
|
||||
(r'adverse.*effect|side effect|risk|complication', 'Adverse effects mentioned'),
|
||||
(r'monitoring|warning sign|emergency|when to call', 'Safety monitoring plan')
|
||||
]
|
||||
},
|
||||
'medication': {
|
||||
'name': 'Medication Documentation',
|
||||
'patterns': [
|
||||
(r'\\d+\s*mg|\\d+\s*mcg|dose|dosage', 'Specific doses'),
|
||||
(r'daily|BID|TID|QID|once|twice', 'Frequency specified'),
|
||||
(r'rationale|indication|because|for', 'Rationale provided')
|
||||
]
|
||||
}
|
||||
}
|
||||
|
||||
|
||||
def read_file(filepath: Path) -> str:
|
||||
"""Read and return file contents."""
|
||||
try:
|
||||
with open(filepath, 'r', encoding='utf-8') as f:
|
||||
return f.read()
|
||||
except Exception as e:
|
||||
print(f"Error reading file: {e}", file=sys.stderr)
|
||||
sys.exit(2)
|
||||
|
||||
|
||||
def validate_content(content: str) -> Dict[str, Tuple[int, int, List[str]]]:
|
||||
"""
|
||||
Validate content against criteria.
|
||||
Returns dict with results: {category: (passed, total, missing_items)}
|
||||
"""
|
||||
results = {}
|
||||
|
||||
for category, checks in VALIDATION_CHECKS.items():
|
||||
patterns = checks['patterns']
|
||||
passed = 0
|
||||
missing = []
|
||||
|
||||
for pattern, description in patterns:
|
||||
if re.search(pattern, content, re.IGNORECASE):
|
||||
passed += 1
|
||||
else:
|
||||
missing.append(description)
|
||||
|
||||
total = len(patterns)
|
||||
results[category] = (passed, total, missing)
|
||||
|
||||
return results
|
||||
|
||||
|
||||
def check_icd10_codes(content: str) -> Tuple[bool, int]:
|
||||
"""Check for ICD-10 code presence."""
|
||||
# ICD-10 format: Letter followed by 2 digits, optionally more digits/letters
|
||||
pattern = r'\b[A-TV-Z]\d{2}\.?[\dA-TV-Z]*\b'
|
||||
matches = re.findall(pattern, content)
|
||||
|
||||
has_codes = len(matches) > 0
|
||||
count = len(matches)
|
||||
|
||||
return has_codes, count
|
||||
|
||||
|
||||
def check_timeframes(content: str) -> Tuple[bool, List[str]]:
|
||||
"""Check for specific timeframes in goals."""
|
||||
timeframe_patterns = [
|
||||
r'\d+\s*week',
|
||||
r'\d+\s*month',
|
||||
r'\d+\s*day',
|
||||
r'within\s+\d+',
|
||||
r'by\s+\w+\s+\d+'
|
||||
]
|
||||
|
||||
found_timeframes = []
|
||||
for pattern in timeframe_patterns:
|
||||
matches = re.findall(pattern, content, re.IGNORECASE)
|
||||
found_timeframes.extend(matches[:3]) # Limit to avoid too many
|
||||
|
||||
has_timeframes = len(found_timeframes) > 0
|
||||
|
||||
return has_timeframes, found_timeframes[:5]
|
||||
|
||||
|
||||
def check_quantitative_goals(content: str) -> Tuple[bool, List[str]]:
|
||||
"""Check for quantitative/measurable goals."""
|
||||
# Look for numbers with units in goal context
|
||||
patterns = [
|
||||
r'\d+\s*%', # Percentages (HbA1c 7%)
|
||||
r'\d+/\d+', # Ratios (BP 130/80)
|
||||
r'\d+\s*mg/dL', # Lab values
|
||||
r'\d+\s*mmHg', # Blood pressure
|
||||
r'\d+\s*feet|meters', # Distance
|
||||
r'\d+\s*pounds|lbs|kg', # Weight
|
||||
r'\d+/10', # Pain scales
|
||||
r'\d+\s*minutes|hours' # Time
|
||||
]
|
||||
|
||||
found_metrics = []
|
||||
for pattern in patterns:
|
||||
matches = re.findall(pattern, content, re.IGNORECASE)
|
||||
found_metrics.extend(matches[:2])
|
||||
|
||||
has_metrics = len(found_metrics) > 0
|
||||
|
||||
return has_metrics, found_metrics[:5]
|
||||
|
||||
|
||||
def assess_readability(content: str) -> str:
|
||||
"""Basic readability assessment (very simplified)."""
|
||||
# Remove LaTeX commands for word count
|
||||
text_content = re.sub(r'\\[a-zA-Z]+(\{[^}]*\})?', '', content)
|
||||
text_content = re.sub(r'[{}%\\]', '', text_content)
|
||||
|
||||
words = text_content.split()
|
||||
word_count = len(words)
|
||||
|
||||
# Very rough sentences (periods followed by space/newline)
|
||||
sentences = re.split(r'[.!?]+\s+', text_content)
|
||||
sentence_count = len([s for s in sentences if s.strip()])
|
||||
|
||||
if sentence_count > 0:
|
||||
avg_words_per_sentence = word_count / sentence_count
|
||||
|
||||
if avg_words_per_sentence < 15:
|
||||
return "Simple (good for patient materials)"
|
||||
elif avg_words_per_sentence < 25:
|
||||
return "Moderate (appropriate for professional documentation)"
|
||||
else:
|
||||
return "Complex (may be difficult for some readers)"
|
||||
|
||||
return "Unable to assess"
|
||||
|
||||
|
||||
def display_validation_results(filepath: Path, results: Dict,
|
||||
has_icd10: bool, icd10_count: int,
|
||||
has_timeframes: bool, timeframe_examples: List[str],
|
||||
has_metrics: bool, metric_examples: List[str],
|
||||
readability: str):
|
||||
"""Display comprehensive validation results."""
|
||||
|
||||
print("\n" + "="*70)
|
||||
print("TREATMENT PLAN QUALITY VALIDATION")
|
||||
print("="*70)
|
||||
print(f"\nFile: {filepath}")
|
||||
print(f"File size: {filepath.stat().st_size:,} bytes")
|
||||
|
||||
# Overall quality score
|
||||
total_passed = sum(r[0] for r in results.values())
|
||||
total_checks = sum(r[1] for r in results.values())
|
||||
quality_pct = (total_passed / total_checks) * 100 if total_checks > 0 else 0
|
||||
|
||||
print("\n" + "-"*70)
|
||||
print("OVERALL QUALITY SCORE")
|
||||
print("-"*70)
|
||||
print(f"Validation checks passed: {total_passed}/{total_checks} ({quality_pct:.0f}%)")
|
||||
|
||||
# Detailed category results
|
||||
print("\n" + "-"*70)
|
||||
print("QUALITY CRITERIA ASSESSMENT")
|
||||
print("-"*70)
|
||||
|
||||
for category, (passed, total, missing) in results.items():
|
||||
category_name = VALIDATION_CHECKS[category]['name']
|
||||
pct = (passed / total) * 100 if total > 0 else 0
|
||||
status = "✓" if passed == total else "⚠" if passed > 0 else "✗"
|
||||
|
||||
print(f"\n{status} {category_name}: {passed}/{total} ({pct:.0f}%)")
|
||||
|
||||
if missing:
|
||||
print(" Missing:")
|
||||
for item in missing:
|
||||
print(f" • {item}")
|
||||
|
||||
# Specific checks
|
||||
print("\n" + "-"*70)
|
||||
print("SPECIFIC VALIDATION CHECKS")
|
||||
print("-"*70)
|
||||
|
||||
# ICD-10 codes
|
||||
if has_icd10:
|
||||
print(f"✓ ICD-10 diagnosis codes present ({icd10_count} found)")
|
||||
else:
|
||||
print("✗ No ICD-10 diagnosis codes detected")
|
||||
print(" Recommendation: Include ICD-10 codes for all diagnoses")
|
||||
|
||||
# Timeframes
|
||||
if has_timeframes:
|
||||
print(f"✓ Time-bound goals present")
|
||||
if timeframe_examples:
|
||||
print(" Examples:", ", ".join(timeframe_examples[:3]))
|
||||
else:
|
||||
print("✗ No specific timeframes found in goals")
|
||||
print(" Recommendation: Add specific timeframes (e.g., 'within 3 months', '8 weeks')")
|
||||
|
||||
# Measurable metrics
|
||||
if has_metrics:
|
||||
print(f"✓ Quantitative/measurable goals present")
|
||||
if metric_examples:
|
||||
print(" Examples:", ", ".join(metric_examples[:3]))
|
||||
else:
|
||||
print("⚠ Limited quantitative metrics found")
|
||||
print(" Recommendation: Include specific measurable targets (HbA1c <7%, BP <130/80)")
|
||||
|
||||
# Readability
|
||||
print(f"\nReadability assessment: {readability}")
|
||||
|
||||
# Summary and recommendations
|
||||
print("\n" + "="*70)
|
||||
print("SUMMARY AND RECOMMENDATIONS")
|
||||
print("="*70)
|
||||
|
||||
if quality_pct >= 90:
|
||||
print("\n✓ EXCELLENT quality - Treatment plan meets high standards")
|
||||
elif quality_pct >= 75:
|
||||
print("\n✓ GOOD quality - Treatment plan is well-developed with minor areas for improvement")
|
||||
elif quality_pct >= 60:
|
||||
print("\n⚠ FAIR quality - Several important elements need strengthening")
|
||||
else:
|
||||
print("\n✗ NEEDS IMPROVEMENT - Significant quality issues to address")
|
||||
|
||||
# Specific recommendations
|
||||
print("\nKey Recommendations:")
|
||||
|
||||
recommendations = []
|
||||
|
||||
# SMART goals
|
||||
if results['smart_goals'][0] < results['smart_goals'][1]:
|
||||
recommendations.append("Ensure all goals meet SMART criteria (Specific, Measurable, Achievable, Relevant, Time-bound)")
|
||||
|
||||
# Evidence-based
|
||||
if results['evidence_based'][0] == 0:
|
||||
recommendations.append("Add evidence-based rationale and cite clinical practice guidelines")
|
||||
|
||||
# Patient-centered
|
||||
if results['patient_centered'][0] < results['patient_centered'][1]:
|
||||
recommendations.append("Incorporate patient preferences and functional quality-of-life goals")
|
||||
|
||||
# Safety
|
||||
if results['safety'][0] < results['safety'][1]:
|
||||
recommendations.append("Include comprehensive safety monitoring and risk mitigation strategies")
|
||||
|
||||
# Medication documentation
|
||||
if results['medication'][0] < results['medication'][1]:
|
||||
recommendations.append("Document medications with specific doses, frequencies, and rationales")
|
||||
|
||||
if not has_icd10:
|
||||
recommendations.append("Add ICD-10 diagnosis codes for billing and documentation support")
|
||||
|
||||
if not has_timeframes:
|
||||
recommendations.append("Add specific timeframes to all treatment goals")
|
||||
|
||||
if recommendations:
|
||||
for i, rec in enumerate(recommendations, 1):
|
||||
print(f"{i}. {rec}")
|
||||
else:
|
||||
print("None - Treatment plan demonstrates excellent quality across all criteria!")
|
||||
|
||||
print("\n" + "="*70)
|
||||
|
||||
# Return exit code
|
||||
return 0 if quality_pct >= 70 else 1
|
||||
|
||||
|
||||
def main():
|
||||
parser = argparse.ArgumentParser(
|
||||
description='Validate treatment plan quality and compliance',
|
||||
formatter_class=argparse.RawDescriptionHelpFormatter,
|
||||
epilog="""
|
||||
Examples:
|
||||
# Validate a treatment plan
|
||||
python validate_treatment_plan.py my_plan.tex
|
||||
|
||||
# Use in automated workflows (exits with error if quality <70%)
|
||||
python validate_treatment_plan.py plan.tex && echo "Quality check passed"
|
||||
|
||||
Validation Categories:
|
||||
- SMART goals criteria (Specific, Measurable, Achievable, Relevant, Time-bound)
|
||||
- Evidence-based practice (guidelines, citations)
|
||||
- Patient-centered care (preferences, functional goals)
|
||||
- Safety and risk mitigation (adverse effects, monitoring)
|
||||
- Medication documentation (doses, frequencies, rationales)
|
||||
- ICD-10 coding, timeframes, measurable metrics
|
||||
|
||||
Exit Codes:
|
||||
0 - Quality ≥70% (acceptable)
|
||||
1 - Quality <70% (needs improvement)
|
||||
2 - File error or invalid arguments
|
||||
"""
|
||||
)
|
||||
|
||||
parser.add_argument(
|
||||
'file',
|
||||
type=Path,
|
||||
help='Treatment plan file to validate (.tex format)'
|
||||
)
|
||||
|
||||
args = parser.parse_args()
|
||||
|
||||
# Check file exists
|
||||
if not args.file.exists():
|
||||
print(f"Error: File not found: {args.file}", file=sys.stderr)
|
||||
sys.exit(2)
|
||||
|
||||
# Read and validate
|
||||
content = read_file(args.file)
|
||||
|
||||
# Run validation checks
|
||||
results = validate_content(content)
|
||||
has_icd10, icd10_count = check_icd10_codes(content)
|
||||
has_timeframes, timeframe_examples = check_timeframes(content)
|
||||
has_metrics, metric_examples = check_quantitative_goals(content)
|
||||
readability = assess_readability(content)
|
||||
|
||||
# Display results
|
||||
exit_code = display_validation_results(
|
||||
args.file, results,
|
||||
has_icd10, icd10_count,
|
||||
has_timeframes, timeframe_examples,
|
||||
has_metrics, metric_examples,
|
||||
readability
|
||||
)
|
||||
|
||||
sys.exit(exit_code)
|
||||
|
||||
|
||||
if __name__ == '__main__':
|
||||
main()
|
||||
|
||||
Reference in New Issue
Block a user