Goals Must Be Based on Assessment
Yesterday I got a real shock when I looked at one of my patient's charts. An OT had evaluated her and used my PT evaluation to write her transfers goals. On the surface this may not sound too bad. I don't understand how she could write goals on something she didn't assess. There was nothing in her evaluation about mobility, not even something indicating mobility as per PT. What's worse my evaluation was performed the day previous to the OT one. The pt's status could have changed between the two. I may be over reacting but I just don't see it.
Let me back up. The OT did do a bed level evaluation. Nothing on her evaluation indicated she moved the patient around. I'm not saying writing "mobility as per PT" and then writing goals would be much better. But doing that there would at least provide an objective basis for the goals. Besides what I wrote was very basic. By not seeing the patient move the OT missed all the intrinsic pieces that go into planning a treatment. I didn't mention hear or trunk control. I didn't describe exactly where the pt placed her hands when transferring or whether she consistently reached for the chair. Some things can't be extrapolated.
The whole point of the evaluation is to determine a patient's functional status. From that we write goals and develop a treatment plan. Sometimes I co-evaluate with an OT. If I don't assess something I see it being assessed. I may ask the OT what the UE strength is which will affect my transfer goals. OT will address the UE strength which also effects my goal. I'm writing a transfer goal, not a UE strengthening goal.
This concerns me because it puts us on a slippery slope. The evaluation is the key for skilled intervention. If OT is basing its treatments on PT assessments it could raise the question of whether OT is necessary since it would appear OT was working under PT. I must appease my OT friends by saying this isn't so. The same would hold if a PT wrote goals based on an OT evaluation. Bottom line, each disciple needs to do its own evaluations.
There could also be a licensure issue. If I assume the OT Practice Act is similar to the PT Practice Act there is something in there about assessments from which to develop individualized POCs. I could argue that skipping part of the assessment but writing goals is in violation of the practice act. I could be over reacting. Maybe I'm the only one who thinks this is a problem. It bothers me because this wasn't an oversight. This OT read my evaluation and decided to use what I wrote rather than moving the patient herself. It was a decision. To me there is no excuse for that. Assessment of transfers can be delayed to a later treatment if necessary. This just seems wrong to me.