Goal Writing 101: Start with a Good Assessment
A good patient history, family interview, chart review and both subjective and objective measures are the foundation of writing goals. Realistically, not all of these components are going to be present for every patient. Some patients are unable to give a personal history due to cognitive or communication impairments. Family members might not be available at the time of the evaluation. Certain formal measures, such as the extensive RIPA-G
(Ross Information Processing Assessment- Geriatric) might not be appropriate for all patients, and so the clinician might turn to family interviews or rating scales, such as the Global Deterioration Scale (GDS)
, or assessments such as the Allen Cognitive Levels
I frequently use the Mann Assessment of Swallowing Ability (MASA) for dysphagia evaluations, but a thorough and descriptive bedside evaluation can be completed using a number of tools. While objective measures with normative data are important, such as the Boston Diagnostic Aphasia Examination (BDAE), I turn to many sources for assessment options. One tried and true source for assessments information is Assessment in Speech-Language Pathology: A Resource Manual by Shipley and McAffee. Whichever assessment tools you choose, be sure that you are completely familiar and comfortable with administering the test. If a patient cannot attend to one instrument, try another means to measure the patient's current ability.
Once current functional ability and deficits are identified, the next step is to compare the patient's current abilities to prior level of performance, commonly abbreviated PLOF. At this stage, thorough family interviews and patient input are important; in their absence, a complete a detailed chart review is the next best source of information. Before a clinician can set realistic goals, she must be aware of the patient's prior abilities. An edentulous patient who has consumed pureed or soft foods for years at home will probably not be an appropriate candidate for a diet texture upgrade to regular foods. In some cases, however, it could be reasonable to expect an improvement beyond the documented PLOF. Possibly a patient who has consumed thickened liquids or was even NPO with a PEG tube placement might have regained swallow function to the level where trials of thin liquids or PO intake are appropriate. This is where a skilled and thorough assessment will benefit you in your goal writing!
Reporting scores on standardized tests helps to justify services and measure progress. However, do not fall into the trap of writing goals based solely on scores. The patient who might not be able to recall information long-term might benefit from memory aids, the development of a functional maintenance plan, and family/ caregiver training to compensate. It might not be important to a patient to subtract serial numbers in his head or identify words in a category or series; maybe he just wants to enjoy completing word searches or play Bingo.