Purpose:
To guide therapists on the use of Therapy Goals/Status to objectively track goal progress throughout the patient's home health episode.
Question Intent:
The Therapy Goals/Status section is intended to track the objective progress of the primary components of your plan of care throughout the episode. It is important that these primary components are added at your Initial Visit (SOC or Evaluation) and documented towards throughout the episode by using the 'status' field to enter the current status at each visit.
Per Medicare Benefit Policy Manual Chapter 7 - Home Health Services, the Therapy Goals/Status portion of our notes helps support that "the condition of the patient will improve materially in a reasonable and generally predictable period of time. Improvement is evidenced by objective successive measurements." This is essential in our Restorative Therapy documentation.
NOTE - see the Maintenance Therapy article to see how Therapy Goals/Status should be utilized for Maintenance Therapy patients.
Response – Specific Instructions:
At SOC (00) and Evaluation (01) visits the Therapist will select their 01 Pathways , which will flow to their 01 New Order, which is where the evaluating therapist will customize the Orders & Goals for a patient-specific plan of care. The Primary Goals (main focus) of this plan of care should then be added as goals in Therapy Goals/Status. Examples of Primary Goals for Physical Therapy would include: Ambulation, Functional Transfers, ROM, MMT, and Objective Tests. Examples for Occupational Therapy would include: ADLs, Functional Transfers, MMT, ROM, and Objective Tests. Examples for Speech Therapy would include: Communication, Swallowing, Voice, and Objective Tests.
To select a goal subject you will click into 'Therapy Goals/Status'. Here you will have large categories such as 'FUNCTIONAL' or 'MUSCULOSKELETAL'. Click the category to open a menu of sub-categories. In the screenshots below the category of FUNCTIONAL and then the sub-category of 'MOBILITY/GAIT' was selected.
Within the MOBILITY/GAIT sub-category a goal subject of MOBILITY: WALK 150FT IN CORRIDOR was selected for the screenshot below. It is within this specific goal that the therapist will enter the Status, Short Term Goal, Long Term Goal (optional), Dates for each goal, and Set Comment (if appropriate). Guidance for each portion is below the image:
Status: This is the observed value of the subject selected at time of evaluation, prior to any skilled intervention.
Short Term Goal: This is a reasonably improved level (improvement from status) in a realistic time frame, based on the patient's presentation and the Therapist's clinical rationale. A Short Term Goal is required for every Therapy Goals/Status item.
Long Term Goal: Similar to STG, this is a reasonable improved level with a realistic time frame based upon patient presentation & clinical rationale.
Set Comment: Comments are to be utilized to add specificity to a goal. Comments are NOT to re-write or free text the goal. Examples of comments would include 'Wish use of 4 wheel walker' for an ambulation goal, 'measured in supine' to define the patient's position for a ROM measurement, 'with use of shower bench' for a shower/tub transfer goal, etc.