At the end of the Treatment Plan, either by date or number of visits, it is necessary to show what happens next. This is the purpose of the Treatment Plan Conclusions box (figure 8) in the lower right of the Plan window.
Figure 8
There are 5 options that can be selected.
•The first option Patient Complied with Plan makes a clear statement in the SOAP note that the patient followed the doctor’s prescriptions and recommendations for care.
•The second option Continue Care w/ changes shows that the care/treatment should be continued and that changes have been made to the Treatment Plan. This selection is mutually exclusive with the next 2 options.
•The third option notes that the Treatment Plan should be continued, but there are no changes to be made in the Treatment Plan.
•The fourth option stating Maximum Benefit Attained is to be used only when the patient is being dismissed from active treatment. If this is included in a SOAP note, and the notes are examined by an insurance company, all services AFTER the date of this entry will be rejected for not being therapeutic.
•The fifth option Supportive/Maintenance Care Advised is to include a statement that the patient was advised to continue care/treatment on a supportive/maintenance basis. Remember that insurance programs do NOT pay for maintenance.