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 Routine (11) visits the Therapist will select Therapy Goals/Status in their visit note and see a limited menu (in comparison to evaluating or reassessing timepoints). The only goals that appear are those that have been defined by the Registered Therapist. It is important to document to at least one status in every routine visit, and ideally more than one as these goals should be the primary focus for the discipline's home health treatment.
To update a Status, the therapist will click on the category and the full THERAPY GOALS/STATUS display will open and be available to edit. The Therapist will click on the 'Status' drop down and choose the appropriate status based on patient presentation for the day's visit.
Every goal that has a Status updated will have a green dot to the left of the goal category.
Note - if the Status remains the same (CGA on previous visit and CGA on today's visit) it is still important to select that status for the visit and achieve the green dot. This will ensure that your assessment of the patient's progress towards the goal is evidenced in the medical record.
The major benefit of Therapy Goals/Status is that the status of each Goal selected is objectively tracked throughout the episode. To see the status from previous visits the therapist can press and hold a specific goal to see the History:
The history will appear with the following columns, this is valuable to see how the patient has progressed throughout the episode:
As goals are met the headers of the goal turn purple for easy recognition. In the example below, the STG of CGA for walking 150ft in Corridor has been met:
Once the highest goal level is met the therapist will have the option to 'Carryover' or 'Don't Carryover'. When Carryover is selected the Goal will remain with the patient episode and will appear on future visits. When Don't Carryover is selected the Goal will not appear on future visits.
The Goals in Therapy Goals/Status are dynamic. A Registered Therapist can update the value (functional level) as well as the date for either short term or long term goals at any visit. The 'Set Comment' feature should be used when updating goals to place a date of when the update occurred and add detail in regards to the reason for the change. An example of modifying the Walk 150ft in Corridor goal is below:
