This comes from Palmetto GBA, a Medicare fiscal intermediary, and it pertains to easily the most crucial aspect of clinical documentation for therapists and, frankly, for any type of clinician. We felt that it was important to share this with our community at large as it is direct instruction from Medicare regarding the shaping of pan of care goals. This information from Palmetto is complete and succinct enough that we are presenting it as is. You can access this article straight from the Palmetto’s website.
WRITING THERAPY GOALS

The Guide to Physical Therapist Practice identifies a ‘goal’ as a remediation of impairments and uses the term ‘outcomes’ for ‘minimization of functional limitation, optimization of health status, prevention of disability, and optimization of patient/client satisfaction. The Guide defines ‘function’ as ‘those activities identified by an individual as essential to support physical, social, and psychological well-being and to create a personal sense of meaningful living.’ The American Physical Therapy Association (APTA) recommends the following components:

  1. Identification of the person
  2. Description of the movement or activity
  3. A connection of the movement/activity to a specific function
  4. Specific conditions in which the activity will be performed
  5. Factors for measuring the outcome
  6. Time frame for achieving the goal

O’Neill and Harris proposed writing goals that contain the following elements:

  1. Who
  2. Will do what
  3. Under what conditions
  4. How well
  5. By when

‘Who’ will always the patient. The goals should never be written as ‘the therapist will do….’ The behavioral statement must reflect the beneficiary performance. Caregivers may be involved in the beneficiary’s care, but they are not the focus of the goal.

‘What’ is the activity the beneficiary will perform. The activity should be observable, repeatable and have a definite beginning and end. Statements like ‘the patient will get stronger’ and ‘the patient will show improvement’ are poorly written.

‘Under what conditions’ is the condition under which the beneficiary’s goal achievement is measured. These may be environmental factors such stairs or grassy surfaces or may be beneficiary factors such as’ with a cane’.

‘How well’ describes the assistance needed. This may be maximum assistance, moderate assistance, minimal assistance or totally independent. This should relate to the baseline assessment information, i.e. ‘requires maximum assistance to ambulate. Experiences SOB on exertion after ambulating 10 feet with cane’.

‘By when’ is the target date to achieve the goal. Goals should be short or long term. A long term goal is the outcome the patient is expected to achieve. Short term goals are goals which lead to the accomplishment of a long term goal. It is helpful, but not required, to label the goals with the word short and long, but the goals should be written in a manner where there are measureable time frames that indicate whether they are short or long. There is no set time frame that defines short versus long. If both short term goals and long term goals are not applicable, the documentation should specify this and explain.

Beneficiaries generally have more than one goal. A good way to assess the medical necessity of each goal is to ask ‘What difference does performing this activity mean to the beneficiary?’ The documentation of the beneficiary encounter should relate back to the goals. Willard and Spackman recommend the RUMBA test:

  • Relevant: functional goals and achievement; patient-specific
  • Understandable: legible and avoid jargon; use of accepted standard terminology
  • Measurable: includes frequency and duration, how long it occurred or how many times
  • Behavioral: measurable occurrences
  • Achievable: reasonable

References:

Guide to Physical Therapist Practice. Rev ed. Alexandria, Va: American Physical Therapy Association;1999
O’Neill DL, Harris SR. Developing goals and objectives for handicapped children. Phys Ther.1982; 62:295–298
Randall, Kenneth E., and McEwen Irene, R. Writing Patient centered Functional Goals. Physical Therapy December 2000 vol. 80 no. 12 1197-1203
Willard & Spackman’s ‘Occupational Therapy’, 11th Edition (2008)
APTA: Defensible Documentation for Patient/Client Management: Components of Documentation within the Patient/Client Model (2011)

P.S. Don’t forget that therapyBOSS enables home care therapy companies to set up goal AND intervention templates very easily. These templates can be customized in any imaginable way and they become available to home health therapists to choose from in their patient care plans. If you need a high-quality set of goal and intervention templates, and haven’t gotten it from us already, let us know!