Home Health & Hospice

Writing goals at your agency: Three common mistakes and how to fix them

Homecare Insider, April 1, 2013

A goal or expected outcome forecasts changes in the patient’s health status and abilities as a result of the care the agency provides. Goals determine interventions, which drive the patient toward positive results. To determine whether the goal is achieved, the language must be quantifiable, and there must be some way to ­measure achievement.

Let’s look at some common goal writing mistakes and how to remedy them.

Mistake #1: The goals on the plan of care are not measurable.

Example: “Blood sugar results will stabilize.”
Remedy: It’s necessary to quantify terms such as “normal” or “stable.” Assessment data can provide the foundation to establish ranges or parameters. Example: “Blood sugar will range from (low level) to (high level).”

Mistake #2: The goals are not realistic.

Example: The record shows that the patient has needed help with bathing, dressing, and grooming since he suffered a CVA five years ago. The nurse listed one goal as “patient will be independent in ADLs.”

Remedy: A lofty goal may look good on paper, but it might not help the patient achieve results. Assess the patient carefully and determine his or her potential for improvement or stabilization, then establish goals that fit within the potential. Remember that for some patients, maintaining their abilities can be challenging but important to their well-being. Example: For the CVA patient, it is important that his abilities do not deteriorate any ­further, so the nurse could set “demonstrate stabilization in ambulation and bathing” as a goal. This goal, using OASIS data elements as the quantifiers, is specific, ­realistic, and achievable.

In addition to not being of value to the patient, a lofty goal can lead to another problem. If the plan of care includes interventions designed to achieve this ­unrealistic goal, such as intensive occupational ­therapy, the intermediary may deny ­payment.

Mistake #3: The goals are stated in broad terms.

Example: “Patient will achieve stable cardiopulmonary status.”

Remedy: The problem with this goal is that it will be very difficult for a nurse to determine when it is achieved. What elements make up cardiopulmonary status? And what does stable mean? Teach staff about the care planning process and how to develop quantifiable goals that are realistic, reasonable, and relevant to the patient’s condition and plan of care.

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