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# Professional Treatment Plan Styling - Quick Reference
## File Location
`medical_treatment_plan.sty` - Available in the assets directory
## Quick Start
```latex
% !TEX program = xelatex
\documentclass[11pt,letterpaper]{article}
\usepackage{medical_treatment_plan}
\usepackage{natbib}
\begin{document}
\maketitle
% Your content
\end{document}
```
## 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

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% 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

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% 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

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% medical_treatment_plan.sty
% Professional Medical Treatment Plan Style
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% 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

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% 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}

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% 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

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% 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

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# 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

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% 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