Setting Goals in Your Therapy Documentation: Audit Pitfalls and Recommendations
By: Cheryl “Chae” Dimapasoc Canon, PT, DPT; OptimisPT Director of Implementation and Compliance
Setting goals within the initial evaluation is a place where many therapists get “stuck” as they try to ensure they satisfy the stringent requirements set by the insurance company. Much of the time it is not due to lack of identifying why the patient is there and what he/she wants to accomplish through therapy, it’s making sure that the insurance company will accept the goals (i.e. if a Medicare patient’s goal is to get back to golf), when it specifies the goal must be related to ADLs and IADLs. Sometimes therapists simply just have a hard time structuring the goal even if they know what the patient wants to achieve. Others still, unfortunately, don’t do a great job of including the patient in creating the long-term functional goal, or the goal is not functional in nature. Windom1, in an unpublished master’s thesis, reported that she interviewed 14 patients in the rehabilitation unit of a teaching hospital. Her study focused on whether patients were prepared to take an active role in their physical therapy, and she found that most patients perceived their role to be that of a passive participant.
After performing audits over the last 10 years, these five considerations have been shown to help therapists that have any challenges with creating long-term functional goals improve their workflow and success in creating the goals.
Ensure the patient is involved in creating the goal and understands their responsibility in helping to achieve the goal.
Patient-centered therapy and goal creation is the hallmark to success in rehab. “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”.2 This also involves the therapist using their expertise to clearly educate the patient on his/her prognosis and expected functional outcomes as they develop the goals with the patient.
One of the biggest challenges we see during this process is the therapist educating the patient on the importance of the “patient’s role” during the episode of care and beyond. Emphasizing this during the IE to encourage compliance with the home exercise program, decreasing activities that continue to exacerbate symptoms and understanding that the therapist is there to guide the treatment and not “fix” the patient, is essential.
For example: The patient is a R hand dominant 70 y/o male who presents with shoulder pain x 2 months after a weekend of cleaning out the garage. He indicates that the repetitive lifting of heavy boxes felt fine during the weekend, but two days later he started having sharp pain on the lateral aspect of his right shoulder. Let’s say you ask the patient his goals and he indicates it is to be able to lift his arm without pain, if the therapist stops there and simply creates as his/her goal “the patient will increase shoulder flexion ROM and strength to at least 85% of WNL so he can raise his arm overhead without pain”. That goal is not bad, but during the subjective you didn’t gather that the patient is primary caregiver for his two-year old grandchild, but has been having difficulty lifting her in and out of the carseat, reaching overhead for objects, and engaging in his passion 3 days a week as he did before his pain started 2 months ago, golf, you would be missing out on a big part of helping the patient to return to what is most important to him in life.
Identify the specific activities during your objective measurements that were part of the patient’s prior level of function that he/she is having difficulty with and wants to return to.
If you establish the baseline of where the patient currently is with that specific activity from a functional level, it will establish a much easier way to provide objective improvement toward the end goal throughout the episode of care (EOC) and at the time of discharge. If you then relate the identified impairment measures to the activity the patient needs to return to, this allows for a defensible, compliant goal.
For our same example, the functional activity would be to lift his 28 lb granddaughter in and out of the car at least 4 times a day.
Make sure to identify the specific objective impairments that are most limiting the activity within the IE.
Documenting “everything under the sun”, such as PROM, AROM and strength of every joint around the area, does not demonstrate clinical reasoning and makes it difficult to create effective documentation. The primary impairment measures that are causing the difficulty with the activity should be specifically identified within the documentation, included in the goal and assessed throughout the EOC.
Back to our example, while a global movement system screen and secondary impairments were identified during the objective exam, the primary impairments causing difficulty with that activity are shoulder flexion AROM to 98 deg with 7/10 pain, PROM shoulder flexion 140 with pain at EOR, and supraspinatus strength 3+/5. Allowing the patient to see how these impairments prevent them from doing the activity, how the specific exercises/activities to address these impairments are essential for the patient to focus on and how reassessing these impairments objectively on a regular basis allows the patient to see progress or lack thereof (and relate it to their compliance with their HEP) should help to achieve better outcomes and lead the patient to accomplishing his/her goal.
The time frame to achieve the long-term functional goal should guide the POC duration.
If you establish the duration as 6 weeks or 90 days, and then only have goals set for four weeks, there is nothing to justify the duration you are requesting. Your established duration within your POC should mirror your longest functional goal. If, for any reason, a referral source or insurance dictates you can only request a shortened duration initially (i.e. 4 weeks) even though you know your patient will need longer, your documentation should clearly delineate your “requested duration” for this part of the EOC but also your recommendations based on your initial evaluation of the patient as to how long the patient will likely require skilled intervention to accomplish his/her functional goals to allow return to prior level of function (PLOF).
Address the goal with the patient on a regular basis throughout the EOC and not just “the minimum that the insurance company indicates”.
There are many reasons to assess and document how close the patient is to accomplishing his/her functional goals throughout the EOC; not just at the time of discharge. Assessing goals multiple times throughout allows the goals to act as a concrete guide and the patient to see where they are currently in perspective to where they are hoping to get to. This should be related to the components of the patient’s POC that he/she has been made responsible for. Better accountability, education and communication with the progress along the way helps the patient to become and remain engaged in their care.
While these suggestions to help with creating compliant and defensible goals seem like common sense, audits performed over the last 10 years suggest that this area of documentation remains a challenge for many therapists. If you’re unsure how your documentation may fare in an audit or if your goals are defensible and compliant based on insurance company requirements, scheduling a Compliance and Efficiency Review could help ease your fears. Contact our Support Team to inquire about this offering if you’re already using OptimisPT as your practice partner. If you’re not part of the OptimisPT family, visit our website at OptimisPT.com to schedule a demo today and see how we can help your practice thrive.
1Windom P . The Preparedness of the Patient to Play an Active Role in Physical Therapy in the Rehabilitation Setting [master’s thesis]. Richmond, Va: Virginia Commonwealth University,1972.
2K E Randall 1, I R McEwen. Writing patient-centered functional goals. Phys Ther. 2000 Dec;80(12):1197-203.
