Skilled Goal Writing for Therapy EMRs......The Essentials
As we take another step deeper into the digital world, electronic medical records (EMR) are an important stop along this path. Patient, physician, practitioner....we will all play an important role along this digital journey. As a patient, your input into your medical record is as vital as is that of a medical provider. Good quality care combines the goals of the patient and those providing treatment. EMRs include written goals for the best possible treatment outcomes.
As a therapist, how do we combine this information from patient and provider in an EMR? First, listen to your patient. Ask key questions related to their visit with you.....and listen...listen....listen. Your patient's responses in words and behavior will guide your assessment and path of treatment. This applies not only to your first meeting, but each and every time you see the patient. EMRs make the second step much easier....enter your patient's responses as well as objective info you noted during tests and measurements. Quality EMRs should include easy to use templates to allow for rapid data entry, reminder prompts, and the ability to automatically transfer data from one report to another with the click of a button. For example, a lumbar spine EMR evaluation template may consist of a series of buttons, enabling the therapist to quickly enter data during a patient visit.
Now comes the good part.....determine the best possible path to treatment. If you listen, patients will tell you what their goals are - "stop this sharp pain in my left hip" or "swing my golf club again" or "get rid of this nagging headache" or "get out of bed by myself." Combine their goals with you, the therapist's, knowledge of functional goals needed to achieve the best results. A quality EMR system will provide goal writing templates with prompts, cues, and prefilled choices to select from.
What should the therapist consider when writing goals?
- What specific activities or movements need to be achieved? (Climbing stairs into home, reach arm overhead to comb hair, or ride a bike) Write a specific goal for each activity or movement patient is working toward
- What measurements (ROM, strength, time, distance, etc) will be used to determine results for each goal?
- What are the specific functional outcomes expected? (Ability to raise shoulder to 150 degrees flexion painfree or improved score on Berg Balance Scale or ....)
- What assistance may be needed for each goal? (kinesio tape, cane, or wrist brace or...)
- What is the timeline or target date for a specific goal? (Short term and long term goals)
- Who will be involved in follow-thru? (patient, parent, caregiver)
Writing goals helps you get to know your patients better....work, hobbies, leisure-time activity, family situation, and home environment. Knowing your patient will help priortize goal setting. Improving shoulder ROM may not be a priority to your patient, but being able to return to work as an electrician is. Listen to your patient, motivate them toward their goals by incorporating specific ROM and strength techniques related to those needed in their job. Explain how using an overhead pulley helps improve shoulder flexion (raising arm overhead repeatedly) which is necessary to pull overhead wires....essential to return to work as an electrician.
As treatment progresses, involve your patient in setting goals:
- Ask for their input as you progress from acute to subacute phase
- Suggest changes in goals (goals which may be more realistic, goals which may be reached sooner than later)
- Give them feedback, let them know how they are doing
- Share goals with family members (if acceptable to patient)
EMRs encourage well written goals, providing keywords and phrases as cues. Well written goals encourage us to get to know our patients, making treatment more relevant and effective. Patient, physician, therapist...everyone wins.
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