A treatment plan is your roadmap for patient care. Creating one From Scratch allows you to manually input clinical data for new intakes. By following these sections, you ensure the "Golden Thread"—the logical link between a patient's history, their diagnosis, and your chosen interventions.
How to Get Started
Navigate to the Patient Dashboard.
Click the Treatment Plan tab.
Select + New Treatment Plan.
Choose From Scratch from the modal options.
The Pillars
1. Case Summary (Symptomatology)
Document the patient's presenting problems, including the onset, duration, and severity of symptoms. Focus on the functional impairments caused by these symptoms to justify the medical necessity of treatment.
2. Biopsychosocial History
Capture the "whole-person" context. This multi-faceted section includes:
Medical & Surgical History: Past surgeries and chronic conditions.
Social History: Support systems, living situation, and social determinants of health (SDOH).
Pharmacological: Current medications, dosages, and known allergies.
3. Strengths (Resource Priming)
At Allia, we utilize a Positive Psychology approach. Identify the patient’s internal resilience and external assets. Research indicates that "resource priming" significantly improves therapeutic alliance and clinical outcomes.
4. Diagnosis & Differential Logic
State the primary ICD-10/DSM-5 diagnosis. Use the Differential Logic field to document why alternative diagnoses were ruled out, providing a transparent clinical trail for audits and peer reviews.
5. Core Challenges
Define targeted areas for change. Assign a Title (e.g., Executive Dysfunction) and a Sub-description linking the challenge directly to the patient’s observed behaviors.
6. SMART Goals & Interventions
Treatment plans are structured to be measurable and actionable:
Goal Title: The high-level therapeutic aim.
Interventions: Evidence-based modalities (e.g., CBT, EMDR, DBT) utilized by the clinician.
Objectives: Specific, measurable patient behaviors or "homework" that indicate progress.
7. Wider Recommendations (Integrated Care)
Supports the Collaborative Care Model (CoCM). Use this space to document referrals to multidisciplinary partners (PCPs, specialists) or suggest self-help resources like books and support groups.
8. Risk Assessment & Safety Planning
Document standardized risk assessments (SI/HI). If risk is identified, you must build a collaborative Safety Plan detailing specific triggers, internal coping skills, and emergency contact protocols.
9. Final Clinical Review
The final segment allows you to view the entire plan in one consolidated view. This is your opportunity to verify that the "Golden Thread" is intact before digitally signing and publishing the document.
How to Publish & Share
Review: Ensure all pillars are completed.
Publish: Click Publish in the top-right corner.
Attestation: Type or draw your signature in the verification modal.
Distribute: Once published, you may Download as PDF or click Send to Patient to share the plan via the Allia Health Client App.