Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 3 › Subtitle 21 - MENTAL HYGIENE REGULATIONS › Chapter 10.21.03 - Requirements for Individual Treatment Plans › Section 10.21.03.03 - Content and Nature of Individual Treatment Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. The individual treatment plan is a
				  comprehensive and thoughtfully written plan based on an initial diagnostic
				  impression and an overall evaluation of the patient's specific needs and
				  problems. It includes an inventory of the patient's strengths as well as
				  weaknesses, and sets forth short-term measurable goals and behaviorally stated
				  objectives aimed at maximal restoration of the patient's adaptive capacity and
				  return to the community as soon as possible. Based on the above goals
				  objectives, a plan of active treatment shall be prescribed which aims at the
				  arrest, reversal, and amelioration of the patient's illness symptoms. There
				  shall be included a long-range discharge goal as well as an estimate of the
				  probable length of inpatient stay needed before transfer to a less restrictive
				  or intensive treatment milieu.
B.
				  The individual treatment plan shall be initially recorded and appropriately
				  updated in the patient's permanent medical record.
C. The initial individual treatment plan
				  shall be developed by members of the mental health professional treatment team
				  who are directly involved in the patient's care including at least one member
				  each from Regulation .02C(1) and (2), of this chapter. The initial individual
				  treatment plan shall be signed by the physician responsible for its
				  development. The names of the other members of the mental health professional
				  treatment team involved in the development of the plan shall be noted adjacent
				  to the signature of the physician.
D. A comprehensive, thoughtfully written, and
				  properly signed individual treatment plan shall be recorded in the permanent
				  medical record, or on a separate form which will become part of the permanent
				  medical record, no later than 15 days after admission.
E. The individual treatment plan shall
				  include or refer to essential written or verbal information which has been
				  gathered, as well as relevant information derived from other parts of the
				  medical record, that will help identify the specific needs and problems of the
				  individual patient. The individual treatment plan shall also include an initial
				  psychiatric diagnosis recorded in the official nomenclature of the American
				  Psychiatric Association, discharge planning data relating to community and
				  financial resources available to the patient, and the legal status of the
				  patient. Information may not be gathered without the consent of the patient or
				  of the patient's parent or legally appointed representative if the patient is a
				  minor or is incompetent.
F. The
				  individual treatment plan shall include a notation of any therapeutic task,
				  labor, recreation, or other scheduled activity to be performed by the patient,
				  including the rationale for these in relation to the treatment plan and the
				  projected goals.
G. The individual
				  treatment plan shall include, when applicable, a description of the patient's
				  individualized educational plan. Special education plans, in conformance with
				  the regulations of the Department of Education, are mandatory for patients
				  through 20 years old.
H. The
				  individual treatment plan shall include, when feasible, patient participation
				  in accordance with Health-General Article, §10-706, Annotated Code of
				  Maryland.
I. Care shall be taken to
				  preserve the confidentiality of the patient-mental health professional
				  treatment team member relationship. Information from a patient's record,
				  including the individual treatment plan, may not be disclosed to any person,
				  organization, or agency except in the case of a court order or with the written
				  consent of the patient or of the patient's parent, if the patient is a minor,
				  or legally appointed representative, if the patient is incompetent.
J. The individual treatment plan shall be
				  periodically reassessed by members of the mental health professional treatment
				  team who are working directly with the patient, including at least one member
				  each from Regulation .02C(1) and (2), of this chapter, including the physician
				  responsible for the implementation of the plan. This reassessment shall be made
				  no less than once every 15 days for the first 2 months for all newly admitted
				  or readmitted patients, and after that, at least once every 60 days.
K. The mental health professional treatment
				  team members who make the reassessment shall place a written entry in the
				  permanent medical record or on a separate form which will become part of the
				  permanent medical record. This entry shall be signed by the physician
				  responsible for the implementation of the plan. The names of the other members
				  of the mental health professional treatment team involved in the reassessment
				  of the plan shall be noted adjacent to the signature of the
				  physician.
L. The initial
				  individual treatment plan and all subsequent reassessments shall be easily
				  identifiable as a separate, comprehensively written, and properly signed entry
				  into the permanent medical record or on a separate form which will become part
				  of the permanent medical record.