treatment plan notes
Introduction
This Mental Health (Neuropsychology): Treatment Plan is to be completed by a fully registered psychologist seeing a person whose treatment is funded by the Transport Accident Commission (TAC). It should be forwarded to TAC as the basis for requesting funding beyond an initial neuropsychological assessment. This treatment plan is principally for the purposes of TAC assuring its liability and that reasonable and effective treatment is funded. The treatment plan is therefore not designed to be comprehensive or to be a substitute for a practitioner’s own assessment, planning or intervention practices. All incomplete forms will be returned, so please give reasons if you are unable to complete a section.
Liability
TAC only funds neuropsychology treatment for mental health problems for which it has liability under the Transport Accident Act 1986. The person must have a current TAC claim and the cognitive, behavioural and mental health condition must have been caused by the transport accident. This treatment plan is for mental health problems that in the professional opinion of the psychologist arise from a transport accident. The TAC does not fund neuropsychology treatment that is not related to the transport accident.
Quality, effectiveness and coordination
The treatment plan enables practitioners to clearly document goals, measures and outcomes. The treatment is expected to be of a high quality, effective, directed at positive outcomes in social, family and work functioning and closely coordinated with the work of other health practitioners and treatments.
Mental health treatment
Mental health treatment refers to a sequenced set of interventions, services, and resources that are delivered to improve a person’s cognitive, behavioural, mental health and well being and must be evaluated for effectiveness by the psychologist. This will include evidence-based interventions and may also include education, advice, practical assistance and service coordination required to meet agreed goals.
Variations or additional treatment to this plan require approval by TAC
Upon completion of the neuropsychology treatment plan the psychologist will need to contact the TAC for approval of funding for any subsequent neuropsychology services. Where significant variations to the type and amount of treatment to be provided, are anticipated these should be promptly advised to the TAC.
Important notes
The following notes each refer to the sections of the Mental Health (Neuropsychology): Treatment Plan. The plan should be completed by a psychologist with full registration, preferably with knowledge and skills in the assessment and treatment of people with acquired brain injury.
1. Person details
A person is someone who has a current claim with the TAC and who is seeking psychological treatment for their transport accident injuries.
2. Referral
As required by the Transport Accident Act 1986, the person is required to be referred to the psychologist by a registered medical practitioner.
3. The transport accident
Give the date and a brief description of the transport accident according to the person’s own account including the injuries received, loss of consciousness, post traumatic amnesia, injuries sustained, and period in hospital.
4. Head injury
Please indicate whether or not the person sustained a significant head injury. If a significant head injury exists, give details of:
§ Head injury severity indicators eg. loss of consciousness, Glasgow coma score at scene, period of retrograde amnesia, period of post traumatic amnesia
§ Radiological evidence eg. findings on CT scan, MRI scan
§ Physical evidence eg. hemiplegia, swallowing difficulties, visual field defects
Please note the source of the information and whether any discrepancies exist between different sources.
5. Current neuropsychological status
On the basis of formal assessment, observed behaviours and history provided, please report information regarding current status and effects on function in the following areas:
Cognitive
§ Intellectual eg. premorbid abilities, current verbal and perceptual abilities
§ Attention eg. speed of processing, focussed attention, multiple processing, distractibility
§ Memory eg. immediate memory span, working memory, new learning (verbal and visual), memory (free and cued recall and recognition)
§ Language eg. reading, comprehension, expression, word finding, fluency
§ Executive eg. planning and organisation, problems solving, abstract thinking, flexibility of thought, insight
Behavioural
§ Drive eg. adynamia, motivation
§ Control eg. impulsiveness, disinhibition, verbosity, tangential
§ Other eg. irritability, fidgety, low frustration tolerance
Emotional
§ eg. depression, anxiety, PTSD, adjustment, coping, fears and phobias
Practical problems would include problems such as difficulties with managing finances, losing their job, schooling difficulties, bullying or being bullied, excessive substance use, effect on community activities, hitting or abusing people, can’t get into a car, forgets things etc.
6. Pre accident status
The person’s pre-accident status should be noted including highest level of education achieved, employment at the time of the accident, other significant previous employment, marital status and living arrangements.
The presence of any pre-existing issues that may affect functioning should also be noted including:
§ Medical conditions eg. epilepsy, diabetes, hypertension, previous head injuries or concussions, medication, sensory problems
§ Cognitive functioning eg. intellectual disability, learning disability, ADHD
§ Behavioural functioning eg. acting out, truancy, substance abuse, aggression, ADHD, impulse control
§ Emotional functioning eg. anxiety, depressions, psychosis, other mental health problems etc
§ Social functioning eg. cultural issues, language spoken at home, homelessness, relationship problems, family dysfunction
7. Previous neuropsychological assessment and treatment
Please note whether the person has previously received neuropsychological assessment or treatment including the name of the provider, dates of service and whether a copy of the assessment report and/or treatment has been received.
8. Identify other risk factors
Risk factors refer to barriers to improvements in cognitive, behavioural or emotional functioning arising from the person’s physical eg. disability or disfigurement; cultural eg. non-English speaking; or behavioural characteristics eg. substance use, avoidant behaviours; or those of the environment eg. unemployment, workplace conflict or legal problems.
9. Agreed care plan and measures
In this section the psychologist should list in priority order the practical goals (across work, family & leisure domains) that the treatment/management plan is attempting to achieve eg. reduce verbal outbursts to five per week. Along with each goal, should be listed the interventions or strategies for achieving the goal, which may include:
§ Direct therapeutic techniques eg. development of behavioural program, training of treaters and carers, monitoring
§ Carer education programs eg. training in behaviour management techniques
§ Consultation with teachers or employers eg. identification of problem solving strategies to be applied to the classroom or workplace
§ Aids eg. a diary
§ Environmental modifications eg. low stimulation
§ Self-management strategies eg. self-management of aids
How progress and achievement of goals are assessed/measured, eg. recording of verbal outbursts, should also be outlined and may include standardised outcome measures, rating scales (client, significant and clinician ratings) the anticipated date of achievement of review eg. April, 2006.
10. Treatment requested for approval
In this section the psychologist gives the duration and number of hours of treatment that TAC is being requested to fund. Within the approved dates and number of hours of treatment the psychologist and the person may determine the frequency of contacts. This may include periods during which treatment is not provided. Please note that both the commencement and completion dates are required in order for the plan to be considered.
11. Multidisciplinary coordination and medications
Treatment coordination refers to health practitioners, professional and lay carers being most effective by ensuring that their treatment is consistent, mutually reinforcing and directed at common goals. In this section list other providers of treatment to this person and their interventions, including especially psychotropic medications and your communication with them. Enter the date of last contact that you have had with the providers listed.
12. Other comments and issues
Please note any other needs that this person has and your recommendations for additional treatment. This may include occupational, physical or social/family needs beyond those that you can address in this treatment plan. The TAC may be able to fund accident related vocational assessment and support and services for other needs where they are reasonable and form part of an overall plan of interventions for the person.
13. Agreement by the psychologist and the person
This plan should be signed jointly by the psychologist and the person to whom they are providing treatment.
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