Keeping Treatment Plans on Headway

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This article contains information that is helpful for Headway providers. If you are a client and have questions, check out our support articles for clients!


What is a treatment plan?

A treatment plan is the cohesive thread that pulls together key information about a given client—from the initial diagnostic evaluation (i.e. intake) through to the unique goals and steps the client agrees to take. This plan creates a foundation for best practices and clinical focus that the provider will address in each session with progress notes.


Why should I add treatment plans on Headway?

Treatment plans help guide care for both the client and provider. On occasion, insurance companies will perform chart reviews to verify the services they cover are appropriate. A treatment plan is a key component of the chart review. 


Are there any specific treatment plan requirements?

Generally speaking, treatment plans for each client should be:

  • Established within the first two sessions
  • Updated at least twice a year, but as frequent as once every 90 days
  • Signed by both the provider and the client

Treatment plans should always be unique to each client, with information specific to that client’s individual presentation and circumstances.


What information belongs in a treatment plan?

During the first session, providers will complete a diagnostic evaluation of the client. From this evaluation, the provider develops a treatment plan with specific goals for the client. This plan creates a thread from the initial evaluation through the progress notes, where providers track how well the client is progressing toward these goals over time.

Specifically, most plans will include:

  • Client’s name and date of birth
  • Type of therapy (e.g. individual, couple, group, etc.)
  • Presenting problem
    • Reason for treatment (e.g. anxiety, depression)
    • Diagnosis (including DSM-V / ICD-10 codes)
    • Symptoms
    • Goals
    • Steps client will take to achieve goals
    • Target date to achieve goals
    • Intervention methods (e.g. medication, mindfulness, CBT, routines, etc.)


What is a treatment plan example?

Note: This is a hypothetical treatment plan based on fictitious people.

  Treatment Plan

Client name: John Q. Public

Date of birth: 01/01/1991

Type of therapy: Individual

Presenting Problem

  • Reason for treatment: John is experiencing anxiety that prevents him from maintaining consistent employment.
  • Diagnosis: Generalized Anxiety Disorder (F41.1)
  • Symptoms: John says he suffers from intense anxiety on Sunday nights that sometimes escalates into an anxiety attack.

Treatment history (summary): Client has seen a psychiatrist, Janet Doe, every six weeks for symptom management, starting in January of 2022.

Goal #1: The client will be able to cope with feelings of anxiety without removing himself from work obligations.
Objective 1: Practice ACT skills to handle work experiences.
Objective 2: Perform cognitive training exercises to evaluate thought patterns to change interactions in work environments.
Desired outcome: Increase coping skills regarding anxiety in the work environment
Target date: 3 months (4/10/2023)

Intervention methods: ACT and cognitive therapy

Client signature and date: John Public (electronically signed 1/10/2023)

Provider signature and date: Susan Practitioner, LLSW (electronically signed 1/10/2023)


Is there a recommended template for treatment plans?

Within the "Clinical" tab of a client's chart in Sigmund, you will see the option to add a treatment plan. If you do want to add your treatment plans on Headway, we provide a template and light guidance for what to include.

Our template offers structure, making it easier to write treatment plans that meet insurers' standards. To use our treatment plan template:

    1. Toggle on "Fill with Template”.
    2. Once you toggle on the template, the free text box will pre-fill with our recommended template. 
      • This structure will help you make sure the right information is included by guiding you through each field.


How does Headway keep data secure?

We’re trusted with individuals’ most sensitive information, and take protection very seriously. We’ve built a secure data infrastructure and platform, maintain SOC 2 and HIPAA compliance, and follow industry best practices regarding cloud infrastructure and encryption. Headway does not sell or upload any data to third party publishers.


Am I required to keep documentation on Headway?

You’re not required to add treatment plans to your session details. That said, insurers occasionally conduct due diligence, and if they make a request for documentation, we’ll ask that it’s supplied within three business days.

If you do want to add your documentation on Headway, we make it a bit simpler through use of our template.


Am I able to export my client documentation?

Yes, contact us and we can provide a secure export of notes or treatment plans you’ve uploaded or written on Headway.

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