The treatment team is responsible for the development and implementation and evaluation of an individualized treatment plan. The treatment plan addresses specific patient problems, prioritizing problems, which are barriers to discharge and/or are identified by the patient as important.
Goals and measurable objectives are formulated with the patient. Interventions are planned identifying the individual team members, who will provide the treatment, the focus, and frequency of the treatment intervention. The interdisciplinary team meeting shall be documented and the results will be recorded in the patient record.