Healthcare Behavior Strategy Document

HEALTHCARE BEHAVIOR STRATEGY DOCUMENT

Patient Name:   Date of Birth:

Medical Record Number:   Gender:

Contact & Insurance Information

Insurance

Assessment Summary

Assessment Date:   Assessor:

Target Behaviors & Baseline Data

Target Behavior 1

Baseline Frequency / Intensity:

Target Behavior 2 (if applicable)

Baseline Frequency / Intensity:

Goals and Criteria for Success

Planned Interventions and Strategies

The interventions below are selected based on assessment findings. Each selected strategy will be implemented with fidelity and documented in progress notes and data collection forms.

Data Collection & Monitoring

Monitoring Frequency:   Next Scheduled Review:

Safety, Crisis, and Restrictive Procedures

This plan authorizes only the specific, documented interventions listed above. Physical restraint or seclusion will be used only if there is an imminent risk of serious harm to the patient or others and only in accordance with applicable law and facility policy. Staff will use the least-restrictive, evidence-based de-escalation techniques prior to any restrictive procedure. Guardian/patient will be notified promptly of any use of emergency restrictive measures.

I acknowledge the policy regarding restrictive procedures: Acknowledged

Authorization, Consent, and Release

By signing below, the undersigned authorizes the implementation of the behavior strategies described in this document. The undersigned consents to reasonable data collection, documentation and information sharing with listed members of the care team for the purpose of implementation, monitoring and treatment planning. The undersigned understands potential benefits and risks, including that interventions may not immediately reduce problem behaviors and that adjustments to procedures may be necessary.

Authorization Expiration Date:

Right to Withdraw: The patient or authorized representative may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

Confidentiality and Privacy: Information collected under this plan is confidential and will be handled consistent with applicable privacy laws and facility policy. Limits to confidentiality include disclosures required by law, reports of abuse or neglect, or imminent risk of serious harm.

Acknowledgment of Notice of Privacy Practices: I acknowledge receipt of the facility's notice of privacy practices regarding my protected health information.

Sign Now