How to Write a Management Plan for a Patient

There are as many different kinds of management plans as there are patients. Doctors rely on management plans that help them predict how they will treat patients in hypothetical situations. These plans come in handy because you can re-use them to treat patients with similar injuries. The most effective management plans are those that begin with precisely defined symptoms. Emergency room physicians, pain management specialists, and even chiropractors draft management plans that help provide consistently thorough treatments to patients with a variety of conditions.

Instructions

• 1

  Articulate the overall purpose of the management plan by explaining the patient's specific condition and your general objectives. For example, you can describe your patient as a child with attention deficit disorder and your objective as an attempt to improve the child's ability to learn. Or your patient may be a trauma victim who needs surgery to repair an ankle fracture.

• 2

  Describe the patient's short-term history, which explains how the patient got to your facility. You can say that she was referred by a family physician for tests to rule out a herniated lumbar disc. Or the patient may have been transported by ambulance from the scene of a motor vehicle collision. Then record the patient's vital signs.

• 3

  Discuss the patient's long-term history. Include past major illnesses, such as a heart attack or cancer. Also specify whether the patient has had prior surgery or has been the victim of past accidents. For example, if a patient presents with severe lower back pain, you should know whether he has been involved in a past accident that caused injury to the lumbosacral spine. That will help you diagnose the condition as either acute or chronic back pain.

• 4

  Establish and record a treatment plan for an office or hospital visit. Decide the exams that must be performed. For example, a chiropractor's patient management plan for a patient with low back pain might say that the doctor plans to perform a straight leg raising test. List all prescriptions, stating the dosages and time periods for taking them.

• 5

  Indicate whether the patient must follow a home treatment plan. For example, orthopedists and chiropractors suggest a home exercise plan for patients with cervical or lumbar spine maladies.

• 6

  Set specific goals and provide a time schedule for achieving them. For example, a management plan for a child with attention deficit disorder might be to improve behavior at home. A plan for a patient with a torn rotator cuff in the shoulder might be to reduce the severity, frequency and duration of the pain. In that case, your management plan would specify the type and length of conservative chiropractic treatment along with a period of regular physical therapy. If symptoms did not subside during that early stage of treatment, your next step in the plan might be to recommend arthroscopic surgery.

• 7

  Decide whether follow-up care is necessary. Explain when the patient should follow up and what should happen during these sessions. For example, you might specify to repeat x-rays, review side effects of medicine or consider surgery if treatment to date has not improved the patient's condition.