Introduction to Clinicient Goal Tracking

This document is an introduction to how goals are handled in Insight EMR. Outpatient Physical Therapists and Occupational Therapists treating Medicare patients should be familiar with the Documentation Requirements outlined in Section 220.3 of Chapter 15 of the Medicare Benefits Policy Manual. This section also provides good recommendations for tracking goals within clinical documentation and, in many instances, has become a defacto standard for tracking goals, even for non-Medicare patients.

Goal Terminology and Best Practices

Functional (long term) goals are derived from the patient interview, questionnaires, scales, or from clinical tests that are more functional in nature than the "traditional" clinical tests used to rule out pathology. Clinical (short term) goals may consist of clinical measurements, traditional clinical tests, and clinical observations. Clinicient recommends tracking and distinguishing between functional and clinical goals in patient documentation so that the clinical goals and treatment plan logically support the functional goal.

Guidelines for Setting Goals Here are a few important principles to consider when setting goals:

  • Goals may be established or edited at any visit, but, typically functional goals and supporting clinical goals and a Plan of Care are all established as part of the initial evaluation.
  • Any relevant finding from the documentation may be used to establish a goal.
  • Any goal may be classified by the therapist as being functional (long term) or clinical (short term).
  • A target date of completion may be set for any goal.
  • The therapist can document changes in relevant goal findings, rate the progress toward goal progression, and document when a goal has been attained.

Example of a Goal

A post op shoulder surgery patient may have pain with overhead activities. His job requires him to lift up to 10 lbs. overhead several times per day. The therapist may establish a functional goal requiring that the patient can demonstrate the ability to lift 10 lbs. overhead repeatedly. During the examination, there may be several clinical findings that relate to this loss of function that may be tracked as clinical goals, for example a loss of normal shoulder ROM and a positive shoulder impingement test. The therapist elects to instruct the patient in ROM exercises and utilize joint mobilization techniques to improve his pain free ROM, ultimately enabling him to achieve the functional goal and establishes a treatment plan and sets reasonable time frames for their achievement. Baseline information used for setting goals is created during the patient evaluation. During the course of treatment, of course, goals may have to be modified. Goals may be summarized in the Goals section of the evaluation, as illustrated below in Insight EMR:

Principles of Goal Setting

Here are some important principles to use in setting goals:

  • Goals may be established or edited at any visit, but, typically Functional Goals and supporting Clinical Goals and a Plan of Care are all established as part of the Initial Evaluation.
  • Any relevant finding from the documentation may be used to establish a goal.
  • Any goal may be classified by the therapist as being Functional (Long Term) or Clinical (Short Term).
  • A target date of completion may be set for any goal.
  • The therapist can document changes in relevant goal findings, rate the progress toward goal progression, and document when a goal has been attained.

Establishing a Goal

As the clinician finds relevant information that would be useful in tracking the patient's progress, there are two ways to track that information as a goal:

  • Right click on a field name to open a drop down menu including the option to mark the documented field as a goal. Once selected, the item will be shown in the topic panel and the star to the right of the item will turn gold, indicating that this item is now a goal.

  • All items tracked as goals are marked by a gold star in the topic panel, and all items not currently tracked as goals will have a gray star. Clicking a gray star in the topic panel will turn it gold, and cause the corresponding item to be tracked as a goal.

Goals tracked using either method will then be listed in the Goals section of your documentation and in the Goal tab.

A target date for establishing a goal may be selected as illustrated here:

Other relevant clinical findings from the patient interview, observation, clinical tests and measurements, subjective scales, or questionnaire results may be also tracked as goals. Here is an example of tracking range of motion measurements as goals:

Organizing Goals

Goals may be flagged as Long Term/Functional Goals and Short Term Clinical Goals. As an example, suppose that in the clinician's judgment, the problem the patient expressed with working full time without a duty restriction should be a Functional Goal. To organize the goals, click on the Goals Tab as illustrated here:

If the Vocational Goal is the Functional Goal, drag and drop associated Short Term/Clinical Goals to the Functional Goal.

If all of the other established goals support the Vocational Goal, the goals would be organized to look like this:

Target dates of the goals may be adjusted at any time:

When deleting a goal, keep in mind that this impacts documentation on other visits and you will no longer be able to track progress against the goal for future visits.

Supporting Goals with Procedures

As clinical procedures are entered as part of the documentation, they may be associated with Functional Goals, as illustrated here:

Completed Goal Tracking

Here is an example illustrating a set of goals after the goals are organized, target dates are set, and relevant procedures are associated with the goals:

 

Goal Tracking Visit to Visit

 

Goals may be tracked routinely as desired visit to visit. Established goals are automatically copied forward to today's visit. Current status of items that are being tracked as goals and a rating of individual goal progression is illustrated here:

Documenting that Goals are Met

When a goal has been achieved, indicate that the goal was met in the progress rating and the date that the goal was met in the Achieved On cell:

Related Links:

Introduction to Clinical Documentation

Launch Clinical Documentation

Enter an Initial Evaluation

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