Writing functional problem statements and goals Study Guide PDF

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how to write goals and problem statements...

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Maddie’s Guide to Clinical Documentation Writing functional problem statements, STG, LTG If you didn’t document it, it didn’t happen Develop a “Problem List”  Identify impacted areas of occupation  Identify contributing factors impacting occupational performance  Set priorities and goals in collaboration with client and/or caregivers ● An active role can lead to improved outcomes and greater satisfaction  A functional problem statement will incorporate the area of occupation and the contributing factors interfering with client engagement Functional Problem Statements  Areas of Occupation  Select occupations that address client goals and allow for reimbursement.  Contributing Factors  Multiple factors can limit client engagement in occupations and affect occupational performance HOW TO WRITE FUNCTIONAL PROBLEM STATEMENTS    

General formula: Client requires [assist level] to [perform occupation or task] due to [contributing factor]. Client unable to [perform occupation or task] due to [contributing factor]. Statements do not have to begin with “Client ______...” Change the order of the formula: [Contributing factor] results in [deficit]. Examples: Client requires moderate verbal cues for three-step meal preparation task due to impaired attention and sequencing. ● Patient requires Min A for threading socks over toes due to decreased dynamic sitting balance and poor trunk control at EOB. ● Client requires moderate assistance to dress upper body due to left hemiparesis. ● Client unable to tolerate five-minute standing task of folding laundry due to decreased endurance and SOB. ● Client unable to navigate from dayroom to personal room due to decreased topographical orientation and poor short-term memory. ● Client unable to drive car due to visual deficits resulting from macular degeneration. ● Left neglect results in decreased attention to left side of face and body while bathing. ● Decreased RUE AROM results in need for Min A from spouse for completion of UB dressing. ● Poor attention to task during showering results in decreased hygiene.

HOW TO WRITE GOALS – STG, LTG Goal Writing Format SMART Significant: Goal achievement will make a significant difference; able to identify what will matter most to client based on strengths, deficits, and collaboration, relevant to needs Measurable: Clear target; able to identify when goal is met Achievable: Goal is reasonable and likely to be met in established time frame Related: Goal has a clear connection to client’s occupational needs as stated in evaluation; short and long term goals relate to each other Time-limited: Goal has an end point; know when to evaluate whether it has been met Ex. Client will cut out outline of a circle in 3 months Goal Writing Format COAST Client: Client will…; includes an action verb Occupation: What will the client do; should relate to the problem statement(s) Assist level: Level of assistance expected  level of independence client is expected to demonstrate; includes physical and/or verbal cues; do not mix levels of assist Specific conditions: Conditions under which client is expected to perform desired action such as location, adaptive equipment, modified technique Timeline: Time frame within which goal is expected to be accomplished; STG vs LTG Example: Client will put on socks with modified independence using a sock aid in three treatment sessions 1. Student will sit quietly during lunch as evidenced by no episodes of food throwing in one month 2. Patient will demonstrate ability to balance his checkbook 80% of the time within two weeks 3. Patient will dress self with 2 or less verbal cues within one month 4. Patient will complete toileting with supervision in two months 5. Client will express emotions in a kind and appropriate reminder without verbal cues within two weeks

Introduction to Goals  A goal is a measurable, narrowly defined end result of therapy to be achieved in a specific time  There are several formats for writing goals, but all will include action words and most will include a measurement of change  Long term goal (LTG): what will be achieved by discharge  Short term goal (STG): small steps that cumulatively result in achievement of LTG ● The time frame will depend on the setting/facility ● Ex. Week, certain treatment sessions   

Goals need to be written in a way that can be understood by third party payers The people who review documentation are looking for indications of progress ● Evidence of progress = changes in function; favorable functional outcomes As a clinician, your documentation should link ● causes and problems  function ● changes  improved function

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Medicare B Guidelines require goals to be functional, measurable (observable), and objective ● This is a good guideline for any goal!

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Functional: self-care, meal preparation, family training, IADLs, Measurable (observable): level of assistance needed (physical or cognitive), measure of strength or ROM, repetitions, time Objective: realistic given diagnosis, achievable given time period and prognosis If not meeting goals – state why ex. Got sick and had setback

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Goal Writing  Goals need to match and be supported by the information in the rest of the evaluation or progress note  When writing goals: ● Write the functional level a patient is expected to achieve ● Write what the client will accomplish, not what you will be doing ● Avoid the word “maintain” unless you are able to justify (neurodegenerative condition)...