Comprehensive Medical Report and Treatment Plan

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Why Create a Comprehensive Medical Report?

A comprehensive medical report and treatment plan are an important part of the treatment process at J. Flowers Health Institute. While many problems may be viewed as a mental health or behavioral problem, they also impact physical health, so a comprehensive assessment that considers both mental and physical health is valuable.

A Quick Example Showing the Benefits of a Comprehensive Report

A 2013 report in Public Health Reviews shows that people with substance use disorders are more likely to develop co-occurring health problems like cancer, heart disease, and sexually transmitted infections.1 Physical health and substance abuse are strongly connected, supporting the need for a comprehensive medical report and treatment plan during addiction treatment.

For example, research shows that over half of people receiving treatment for substance abuse die from consequences of tobacco use, such as cancer of the mouth or throat. Furthermore, these cancers are 7 times more likely among those who smoke and 6 times more likely among people who drink alcohol.1

In addition, heavy alcohol consumption is the leading cause of high blood pressure among adults. Given this information, it is clear to see why a complete medical report is part of a treatment plan.

Making a Comprehensive Medical Report

A comprehensive medical report is developed after a team of medical professionals performs a full medical evaluation.

This team includes specialists from multiple disciplines, such as:

Psychiatry
Psychology
Nutrition
Chronic pain
Addiction Treatment
General Medicine

 

The team works together to evaluate medical history and current health status. The team will assess all facets of health, including diet and lifestyle choices like exercise habits and smoking status. A physical examination will also be administered, during which a physician will evaluate everything from the eyes, nose, and throat to the heart and lungs.

Checking Vitals and Exploring Health History

A medical evaluation also includes an assessment of vital signs like heart rate and blood pressure. A medical professional will discuss health history, including any past surgeries, illnesses, hospitalizations, or medication use. Also, the team will assess the presence of any current health problems that warrant further treatment or evaluation. Some additional assessments may include laboratories, cholesterol testing, x-rays, hormone testing, or screenings for conditions like cancer, diabetes, and sexually transmitted diseases.

Professionals from psychiatry or psychology may screen for conditions like depression or anxiety. In total, the medical report is a summary of any information learned during the comprehensive medical evaluation. It can include:

A summary of health history and current health status

Results of screenings and labs

Diagnoses of any current health problems

The Goal of a Comprehensive Medical Evaluation

The goal of a comprehensive medical evaluation is to assess if there are any co-occurring health conditions that should be treated. Screenings and labs conducted during this evaluation can determine whether the symptoms being reported are supported by medical test results. The medical report will contain a summary of these results, as well as whether or not they support the presenting problems and symptoms. Ultimately, the medical report contains diagnoses as well as information about overall health-related needs during treatment.

Individualized Treatment Plans

Using a comprehensive medical report, a team of experts then creates an individualized treatment plan. Because each patient is unique, no two treatment plans will be the same. These are examples of common types of treatment plans:

Mental Health Treatment Plans

These treatment plans can include those tailored to individuals living with depression or anxiety. Such a treatment plan is common among people dealing with a substance use disorder, as research shows that nearly one-third of those who have had an addiction during their lives have one or more anxiety disorders. Also, those with depression are about twice as likely to experience addiction, whereas those with bipolar disorder can be up to seven times as likely to develop an addiction.1

Mental health treatment plans include steps for coping with symptoms, developing healthier ways of thinking, and addressing any co-occurring issues, like addiction, that have arisen as a result of mental health disorders.

Cancer Treatment Plan

Treatment plans for people who have been diagnosed with cancer are also common and may need to address underlying substance abuse issues. In fact, studies show that at least one in five people living with cancer runs the risk of developing an opiate use disorder. People with a cancer diagnosis may abuse opiate medications, initially prescribed for cancer-related pain, to cope with the stress of being chronically ill.2 A cancer treatment plan will, therefore, include services to treat or manage cancer, as well as those that healthily address cancer-related pain, which may include treating an underlying opiate use disorder.

Chronic Pain Treatment Plan

A chronic pain treatment plan can help people who are living with this condition to find relief that does not result in opiate addiction. Unfortunately, the use of opiate medications for chronic pain can result in opiate abuse, and these drugs may not even be effective in treating pain. In one study, acetaminophen was just as beneficial as opiates, and morphine doses as high as 100 mg per day were hardly more effective than a placebo.3 A treatment plan for chronic pain can provide alternative methods of treating this condition.

Substance Abuse Treatment Plan

According to the Substance Abuse and Mental Health Services Administration, 20.2 million American adults have a substance use disorder, so treatment plans for this condition are also common.4 These treatment plans include a range of services to help people detox from drugs and live a life that is free from substances. If withdrawal symptoms occur, a detox program may be necessary while the body rids itself of substances. Depending on individual needs, a substance abuse treatment plan may include inpatient or outpatient services.

20-Million-American-Adults-Have-a-Substance-Use-Disorder

Setting Treatment Goals

Just as a treatment plan will vary based upon individual and unique needs for each person, the goals of treatment are also individualized. These goals should be specific and include some manner for measurement so that everyone can determine if and when goals have been met. Treatment goals may include:

Improved Mental Health

A patient who is living with depression or anxiety may have a treatment plan goal that includes improved mental health. For example, a goal might be to reduce a score on a depression scale by 20% by the end of treatment or to reduce the number of daily disruptions that anxiety causes in his or her life.

Sobriety

For someone who has been struggling with a substance use disorder or addiction, sobriety is often a treatment plan goal. For example, someone who is recovering from opiate use disorder may have a treatment plan goal to remain sober for six months, as evidenced by negative urine drug screens.

Pain Reduction

A patient with a chronic pain treatment plan will typically have a goal of reducing pain. For instance, a patient who begins treatment with low back pain that rates at a 7 on a scale of 1 to 10, with 10 indicating the most severe pain, may aim to reduce average daily pain ratings to a 2. Meeting this goal would make the pain more manageable so it interferes less with daily functioning.

Exploring Treatment Options

In addition to including goals, a treatment plan includes various services. For those with a treatment plan, there are a variety of common treatment options:

Psychotherapy

Psychotherapy, also known as counseling or talk therapy, is common among those who are in treatment for mental health conditions like anxiety or depression. Psychotherapy can help people to identify the underlying causes of mental health disorders and develop healthier coping mechanisms and ways of thinking.

Addiction Treatment

This is another common option for treatment plans. Those who are living with substance use disorders will undergo some form of addiction treatment, which can involve individual counseling, group counseling, educational groups, support groups, and medication.

Physical Therapy

For those living with chronic pain, physical therapy is an option that can be included in a treatment plan. The research supports the use of this treatment option, as a study in the American Journal of Physical Medicine & Rehabilitation found that a four-week physical therapy intervention significantly reduced neck pain while improving range of motion and physical performance when compared to a control group.5

Radiation Therapy

For those living with cancer, radiation therapy is a common form of treatment on the treatment plan. This option may even reduce cancer-related pain. According to scientists, clinical studies show that as many as 80% of patients with uncomplicated bone metastases enjoy pain relief with external beam radiotherapy.6

Comprehensive Medical Reports Improve Your Treatment

A treatment plan includes a variety of services aimed at improving overall health and wellbeing as well as checkpoints to meet treatment goals. Specific treatment plans are developed after a comprehensive medical assessment, which is thorough and identifies all underlying issues that may be contributing to any presenting problems. An advantage of a comprehensive medical report and treatment plan is that this sort of service assesses the entire person, providing the optimal level of care for true health and recovery.