Before discussing the details of writing goals, it is important to discuss the relationship between Expected Outcomes and Anticipated Goals in the note. The Expected Outcomes section of the note describes the final functional status to be achieved by the end of the skilled therapy intervention provided. Expected Outcomes are commonly called Long Term Goals. The Anticipated Goals, commonly called Short Term Goals, are the stepping-stones for achieving the Expected Outcomes. Determining the Expected Outcomes and Anticipated Goals is based on a combination of many factors, including the patient's diagnosis, other medical history, clinical judgment from the therapist, and results of the examination process. Some facilities will elect to set only one set of goals (Anticipated Outcomes) if the patient will need skilled intervention for only a short period, such as two or three visits in an acute care setting. However, if the patient will participate in therapy over a longer period of time, both Expected Outcomes (Long Term Goals) and Anticipated Goals (Short Term Goals) are set; this practice is more common in outpatient and inpatient rehabilitation settings.
The organization of the note regarding Expected Outcomes and Anticipated Goals can vary widely by facility, because it is up to the facility's discretion as to where they place information in the patient's note. Some facilities place these items as a part of the Assessment (A) section of the note. This holds true for both handwritten and electronic health record (EHR)-generated notes. With an EHR-generated note, the placement of these components varies widely by both the EHR program utilized and how the individual facility has customized the format for their unique needs. As a rule, it is best to enquire at your clinical site and/or place of employment as to how their notes are laid out in the documentation system utilized. For the purposes of this textbook, you are to write Expected Outcomes and Anticipated Goals as part of the Plan of Care. These Expected Outcomes should describe the final functional status to be achieved through therapy at the end of the patient's entire course of physical therapy, potentially across facilities or care settings.
Reasons for Writing Outcomes and Goals
Outcomes and goals are written for several reasons:
To help the therapist plan interventions to meet the specific needs of the patient
To set objective measures, to ensure progress with treatment, and to monitor the effectiveness of the interventions
To assist with justifying the need for skilled intervention (for purposes of third-party payment)
To communicate the goals of therapy intervention to other healthcare professionals who also care for the patient
The Basic Structure of Expected Outcomes and Anticipated Goals
Before writing goals specifically, it is necessary to know the ABCs of writing goals. Like an educational learning objective, a good goal for patient care contains the following four elements:
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