Documenting the Plan Flashcards
What is the POC?
A plan for the entire treatment of the pt
What does the POC include?
- Short-term goals
- Long-term goals
- Intervention plan
- Discharge plan
Patient care goals must be ____ and ______.
Functional
Measurable
4 Reasons why we write patient care goals?
- Help plan interventions
- Set priorities
- Assist with monitoring cost effectiveness
- Communicate
Describe the ABCDs of Goal Writing
Audience
Behavior
Condition
Degree
Describe the audience of goal writing
Ask the question who will exhibit the skill?
- Almost always the patient - Can be family members or the patient with family members - Never the therapist
Describe the behavior portion of goal writing
Describes what the person will do
- Always an action verb and functional behavior, such as demonstrate, list, state, explain
Describe the condition / circumstances that are necessary in order to write patient goals
- Circumstances under which the behavior must be done (position, equipment, etc.) must be Conditions necessary for the behavior to occur
Describe the degree portion of patient goals
This section describes how well the behavior will be done
- Must be measurable and observable values - Specific time span - Express in terms of function
What is usually the longest part of LTGs?
The degree portion
- describes how long it will take a pt to achieve a certain goal
What are STGs?
Smaller goals that are accomplished first to lead up to LTGs
What is the most common time span for STGs?
approximately 1 week
STGs may be as short as ____ and may be as long as ______.
1-2 days
2-3 weeks
What do STGs depend on?
the pt’s diagnosis, prognosis, and general medical condition
What is the time span from LTGs?
It really depends…can be a week, a month, a year or longer
What do LTGs depend on?
the pt’s diagnosis, prognosis, and general medical condition
Time span = the _____ length of time during which the pt will be seen in therapy
TOTAL
What do LTGs describe?
the final product to be achieved by therapy listed in terms of function
5 Tips for writing STG & LTG
1) Look at the pt problem list or impairments
2) Look at the pt functional deficits
3) Look at the pt goals
4) Start with the LTG and then create STGs to reach the LTG
5) List in order of priority with the most important goal listed first
3 Conditions in which Revisions to STGs & LTGs required?
1) The patient’s condition changes and does not allow progression to functional level originally established
2) The patient’s condition changes and allows for progression to functional level beyond those originally established
3) The time span set is no longer appropriate
What does the intervention plan include?
A plan for the interventions the pt will receive while in therapy
What should the intervention plan be based off of?
STG and LTG
What are a few things the intervention plan may include?
- Modalities
- Ambulation
- Exercises
- Neuromuscular Re-education
- Home Program
- Pt Education
What does the discharge plan include?
- Exercises
- Assistive device(s) needed
- Referral to other services if needed
