Documenting Goals

CHAPTER 10


Documenting Goals



LEARNING OBJECTIVES


After reading this chapter and completing the exercises, the reader will be able to:


1. Describe the important aspects of writing goals at the participation, activity, and impairment levels.


2. Distinguish between short-term and long-term goals.


3. Describe the essential components of a well-written functional goal.


4. Identify poorly written goals and make modifications to goals.


5. Appropriately document participation, activity, and impairment goals for a written report.


This chapter presents the Goals section of the initial evaluation. Establishing anticipated goals and expected outcomes is a critical part of the process of establishing a plan of care for a patient and is one of the cornerstones of physical therapy documentation. The Guide to Physical Therapist Practice (APTA, 2001, p. S38) defines anticipated goals and expected outcomes as



PTs, in collaboration with patients, set goals designed to measure progress toward specific expected outcomes. Therefore the term goal is used throughout this book to document this process. Through documentation of these goals, therapists express their knowledge of a patient’s specific problems, formulate the prognosis, and provide the foundation for developing an intervention plan specific to the individual patient’s needs.


Three important aspects about the process of setting expected outcomes should be emphasized. First, in establishing goals, the PT makes a professional judgment about the prognosis, that is, the likelihood of functional recovery. The prognosis is, in effect, a prediction about the future, and therefore it depends on a very high level of skill, knowledge, and experience. Nevertheless, it should not be assumed that establishing a prognosis requires years of experience. Indeed, one of the most beneficial aspects of evidence-based practice is the increased availability of information about prognosis.


Second, the process of setting goals is a collaborative effort between the therapist and the patient and often the patient’s family and other professionals. Randall and McEwen (2000) have developed this point cogently. They have proposed a method for writing goals that is very similar to the one proposed in this textbook. The term patient-centered is especially useful because it emphasizes that successful therapy mandates that the goals be focused on what the patient wants to accomplish. As they comment, “For goals to be truly patient-centered, they should be relevant to the patient’s desired outcomes, not to what the therapist thinks is ‘best’ for the patient” (Randall & McEwen, 2000).


Third, goals should guide the therapeutic process throughout its course. If rehabilitation is perceived as a journey, goals are a statement of the destination that the patient and the PT are attempting to reach. For goals to function effectively as a guide they should be referred to during every treatment session, and between sessions as well, as the patient implements his or her “home program.” Thus the goals are not simply documented during the initial evaluation; they should be referred to or addressed in every treatment or progress note. A method for doing this using the SOAP note format is presented in Chapter 12. Case Examples 10-1, 10-2, and 10-3 at the end of this chapter provide sample documentation of goals written in initial evaluation reports in various clinical settings.



CASE EXAMPLE 10-2   Documenting Goals


Setting: Acute Care Hospital


Name: Mario Nieto  D.O.B.: 10/14/33  Date of Eval.: 11/5/09




CASE EXAMPLE 10-3   Documenting Goals


Setting: Outpatient


Name: Keisha Brown  D.O.B.: 1/9/93  Date of Eval.: 2/12/09




A Traditional Approach: Short-Term and Long-Term Goals


The traditional approach to documenting goals has been to distinguish between short- and long-term goals. Here the distinction is based primarily on the time course of rehabilitation. For example, a typical long-term goal might be:



A short-term goal related to this long-term goal might be:



Thus the concept of a short-term goal is that it is an intermediate step toward achieving the long-term goal. This approach can be useful, especially in rehabilitation settings where treatment may continue for an extended period (see Case Example 10-1). However, with changes in the health care system and especially in payment policy, patients are less likely to be treated over an extended period by a PT. A notable exception is pediatric school-based therapy, where children are often seen over the course of a year. In this situation, long-term goals and short-term objectives are typically written (see Chapter 14).



CASE EXAMPLE 10-1   Documenting Goals


Setting: Home care


Name: Martin Jones  D.O.B.: 5/7/54  Date of Eval.: 5/10/09









Writing Goals at Three Different Levels


Although in certain instances establishment of short-term intermediate goals helps to provide a guiding framework for a complex course of rehabilitation, this text advocates a different approach in which the therapist establishes expected outcomes at three different levels: participation goals, activity goals, and impairment goals.





IMPAIRMENT GOALS (OPTIONAL)


Impairment goals express the expected outcomes in terms of the specific impairments in body structures or functions that contribute to the functional limitations. Although the emphasis in this text is on writing activity or functional goals, in some situations one or more goals of therapy involve reduction or elimination of impairments. Therefore in such cases explicit setting of impairment goals is reasonable so that outcomes can be monitored. For example, an impairment goal may be to achieve 4/5 strength in the quadriceps, increase range of motion (ROM) of knee flexion to 110 °, or improve symmetry of step length during gait. Impairment goals also may be viewed as short-term goals used as benchmarks on the way to attaining activity goals. These goals are particularly important for patients who may have serious activity limitations, such as immediately after a stroke or spinal cord injury. Changes in impairments, such as strength, may be the only immediate demonstration of improvement in the patient’s status, and therefore they may be more sensitive indicators of progress. The goal of therapy is then for the improvements in impairments to ultimately result in improved functional activities.



Linking Impairment and Activity Goals


Impairment goals must always be linked to the activity goals in some way. This linkage should be explicitly stated in the Assessment section. Sometimes therapists link an impairment goal to a activity goal when they are writing the goal. For example, “Pt. will increase knee flex ROM from 85° to 95° so that patient can rise from a seated position” (93° of knee flexion is required for rising from a seated position; Laubenthal, 1972).


Although this is an acceptable strategy that is often recommended, it may be more concise and clear to simply write a functional goal related to reaching items in tall cabinets. The increase in shoulder flexion may or may not be an important impairment/short-term goal, depending on the factors contributing to the activitiy limitation. A primary reason that such goals often are not useful is that typically more than one impairment contributes to an activity limitation. In the previous example the patient may have a strength deficit in addition to loss of ROM in the shoulder. Thus the patient could attain the goal of improving ROM in the shoulder, but if strength was not improved, the patient would still not be able to reach items in a tall cabinet. The discussion of the often complex link between any observed limitations and impairments may therefore be more appropriate for the Assessment section.


In summary, the focus of therapy should almost always be on achieving meaningful activities, and reaching the impairment goals should be subordinate to attaining the activity goals.



Fundamentals of Well-Written Functional Goals


Skillful goal writing is deceptively difficult; the PT easily may fall victim to several pitfalls. Therefore the process of learning how to write goals begins by defining the fundamental characteristics of goals and illustrating some of the pitfalls.

Related posts:

Documenting Reason for Referral: Participation and Social History, Legal Aspects of Documentation Documentation in Pediatrics Computerized Documentation Essentials of Documentation Documenting Impairments in Body Structure and Function

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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Documenting Goals

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