Form Cms-725 - Surveyor Worksheet For Psychiatric Hospital Review:two Special Conditions Page 2

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SECTION III: COMPONENTS OF THE PATIENT’S TREATMENT PLAN AND SURVEYOR COMMENTS
1) Goals-long range
Interventions
short term
Identified Problem(s)
What? By Whom?
Surveyor’s Comments
2) Timeframes
How will this effect outcome?
projected outcome
Page 2
Form CMS-725 (09/94)
(OPTIONAL)

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