These question aren’t asking about advice as this forum was intended. These are questions about a healthcare practice I still don’t understand. This may be a more “behind the scenes” healthcare question.
“Goals in medical documentation”
They exist in every rehab professional’s medical documentation.
I understand how to write them, my question is why?
I’ve asked these questions and discussed them with numerous licensed rehab professional. I’ve yet to receive an answer that satisfies me. So here I am posing it to the BBM crew:
When did PT’s start putting goals in their documentation? I’ve spoken to individuals with over 40 years experience and they’ve always done it. So when did it start?
Why do PT’s write goals for other people?
I cringe when I think about the hours spent in school or spent on clinicals writing and re-writing goals to satisfy a professor or instructor.
I’m occasionally given the answer with some form of “patient centered” flavor to it. In reality, by the time the clinician gets to the “goals” of a SOAP note, they trying to get it over with. (Insert smart phrase: Patient will decrease pain by 2/10 to improve ability to perform ADL’s).
If the answer is “to satisfy the insurance provider/payor.” Fine, we do a lot of things for that reason. But I struggle to get on board with the idea rehab professionals enjoy writing goals or they are needed to drive practice.
So there it it:
When did the concept or requirement start that rehab professionals have to insert/write goals at the end of their medical documentation?
Why do it anyway?
This is an excellent question and one to which I have never really heard or looked for an answer. I fully agree with your sentiment and if you are talking about smartphrases I can only assume you are using Epic. I have been on three different iterations of the software now with each presenting with different problems. One thing I have noticed though is the propensity to “find problems to justify goals” as it were. I have seen notes listing 17 different variables that likely do not matter in order to justify one goal or using an outcome like “pt will improve multifidi strength to x/5 in order to decrease low back pain” where 1) we can’t test multifidi strength in isolation, MMT sucks in general, and there is no correlation with that outcome and a reduction of LBP." But I digress. What I have started doing more is writing a goal to the effect of “pt will tolerate 30 minutes of moderate level physical activity without increase in symptoms to meet physical activity guidelines” as it is intentionally broad, but also very justifiable from a research standpoint.
All that to say, I am pretty sure we do a lot of what we do because “that is the way we have always done it.”
Its re-assuring to know I’m not the only one left without an answer (that said, I’ve not met a PT with an answer).
I too find myself writing broad, research supported goals, unless the patient comes straight at me with their own personal (and realistic) goal.
I’ve also found myself wondering:
My dentist has never asked me what my goals are.
“Patient will brush and floss 2x/daily to reduce dental caries”
I’ve never been asked by my PCP what my goals are.
“Patient will improve adherence to prescription medication by 20% to reduce…”
I’ve not heard an orthopedic surgeon ask someone their goals
“Patient will survive surgery???”
ER docs aren’t asking about goals
“Patient will survive 24 hours and not be re-admitted…”
I understand each provider asks questions to establish the patients wants/needs/etc, but I don’t think any waste time documenting them.
Overall, the whole concept continues to leave me more uncertain as I practice longer.
My complete guess, it stems from the formation of the “PT diagnosis” that happened when we felt the need to differentiate ourselves. That and a combination of the rampant abuse of the system that went on in the 80’s and 90’s. But hey, we can write goal of “Patient will reduce the incidence of palpable trigger points by 40% in order to reduce the risk of scar adhesions and maximize participation in ADLs” and apparently that is perfectly fine as well. I’m holding out for “Patient will leave therapist cookies to demonstrate independence in UE motor control with ADLs”