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 Agency Discharge (18) and Discipline Discharge (19) visits the Therapist will select Therapy Goals/Status in their visit note and see full menu of available goals (in comparison to routine visit that only shows what has been associated to the patient). To quickly view the Therapy Goals/Status that are associated with the patient the therapist can go to Medical Records (top right menu) and select Therapy History. This will open up the Therapy Goals/Status goals that should be addressed at the Discharge Visit:
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.
As this is the last visit for the discipline, the goal will either be Met (appear in purple as shown in image below), or Not Met. If the goal is Met, no further documentation is required within the Therapy Goals/Status feature. If the goal is Not Met, please use the 'Set Comment' button to place the visit date and rationale for the reason the goal was not met.
Goal Met Example:
Goals Not Met Example (with comments):
NOTE - It is important to document the status of each goal at the Discharge visit to comply with Medicare Benefit Policy Manual Chapter 7 - Home Health Services requirements, which note that "The therapist must document the measurement results which correspond to the therapist’s discipline and care plan goals in the clinical record."
One 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. This information can be utilized to see progress, plateau, or potentially regressions that may need to be addressed.
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. It is recommended to select 'Don't Carryover' for all Therapy Goals/Status on a Discharge Visit.
