Occupational Therapy Goals

  • Tuesday, April 6, 2021
occupational therapy goals, occupational therapy treatment plan, occupational therapy evaluation

Occupational therapy goals and how to create excellent occupational therapy goals; SMART goals; examples of goals with all of the necessary components; and do’s and don’ts for writing OT goals will be covered in this blog post.

You have already conducted a full evaluation on your client. Now it is time to come up with occupational therapy goals for their treatment plan. The next step is to take the data you collected and translate it into meaningful goals to pursue in occupational therapy. If you practice in pediatrics, the goal should be also be important to the parent or caregiver. Information about goals comes from the occupational profile, standardized testing, reason for referral, and your analysis of the evaluation. The data you collected in the evaluation serves as baseline data. This will help you track progress for your client, inform intervention choices, and ultimately give your client a foundation for success.

SMART Goals

A SMART goal is an acronym for a goal that consists of five different essential factors: Specific; measurable; attainable; relevant; and time-based. This is a great tool for occupational therapists and other health professionals when composing goals and checking that each goal contains all of the essential components.

Specific: This section refers to the tangible outcome. What does the client want to do? For example: Laurie will complete a 5-step task of making tea; Aaron will cut out a circle; Mary will wash her hands. Be sure that you know the client’s current level of performance.

Measurable: This piece is essential for both reimbursement and tracking progress. It gives concrete data on the degree of the client’s performance. The measurable piece of a goal can come in many different forms: Duration (within five minutes); pain level (client reporting a maximum pain level of 4/10); portfolio collection (for something tangible the client created); client satisfaction (using the Canadian Occupational Performance Measure). Another important factor to consider: Who will track the data? Sometimes therapist collection of data is sufficient but where carryover is essential, the therapist may want to designate a teacher, health professional, or caregiver to track the data.

Attainable: This is an important area to consider how much time you have with the client along with their current level of functioning. Can the client re-learn to tie their shoes in their short acute care stay? Likely not. However, the same client may be able to wash their hands with a visual aid and no more than one verbal cue.

Relevant: An essential component for occupational therapy, it is important to ensure that your client wants to reach their goals. Motivation can have an enormous impact on progress. While the process of coming up with relevant goals begins when you take your client’s occupational profile, it should be considered throughout the process. If you are unsure, share your goal ideas with your client and ask for feedback.

Time-based: In a written occupational therapy goal this may look like “within five days,” “at the time of discharge,” or “by April 1st, 2022.” The time given will vary by clinical setting. In an acute care setting, goals may be written for three days. Inpatient rehab goals could be several weeks long. In the educational system, students who have an IEP often have goals written for an entire year.

Examples of SMART Occupational Therapy Goals

By June 15, 2022, given one verbal cue and environmental set-up by therapist or caregiver, Joseph will prepare a cup of coffee, as measured by his ability to complete the task in 4/5 attempts.

By September 30, 2022, given adaptive paper, Kate will correctly sequence letters with 80% accuracy in 3 out of 4 consecutive trials, as measured by portfolio collection.

By January 3, 2022, to demonstrate improved bilateral coordination and self-care skills, Brandon will don and doff shoes independently in 4/5 trials, as measured by caregiver report.

The Do’s and Don’ts of Occupational Therapy Goal Writing

• Don’t write a goal that you do not have baseline data for. Without this foundation you will not know what criteria to add for your client or if the goal is attainable or even necessary. This would also provide a significant challenge for writing progress notes.

• Do consider their prognosis when selecting goals. Criteria for an otherwise healthy client recovering from an hip replacement will vary greatly from a client who is living with chronic multiple sclerosis.

• Don’t assume that an ADL or IADL is meaningful to your client. While a grocery shopping goal can encompass many of the skills that your client is working on, they may greatly prefer to order their groceries to be picked up.

• Do consider goal-writing exceptions for Individualized Family Service Plans (IFSPs). Since in this practice setting, the family unit functions as the client, goals are often written to be simplified. For example, a goal may be measured upon whether the child completed a task or not.

• Don’t put in more than one measurable objective. This is a common mistake that makes tracking goals more challenging than necessary. Instead, make sure you prioritize and then separate important goals into unique objectives. For example, rather than “use a dynamic tripod grasp to draw a 5-part person” create one objective for grasp and another objective for visual motor skills.

• Do create a system for tracking data over time. This may look like a visual representation on graph paper or computer software that automatically generates a visual as you input numerical data.

Summary

Creating intentional occupational therapy goals is essential for client motivation, tracking progress, helping with occupational therapy SOAP notes and getting reimbursed, and ultimately, client success. By listening to your client and creating SMART goals you can ensure that your client’s goals have all of the necessary components for them to be successful.

Looking for a platform to complete your plan of care, documentation, billing, and more, all in one place? TheraPlatform offers an all-in-one EHR system along with teletherapy conferencing software, built-in features, and more. TheraPlatform even has a feature that creates a visual representation of your client’s goal progress over time. No more flipping through pages of documentation to check in on your client’s progress. Sign up for a 30-day free trial (no credit card needed).



Resources
occupational therapy SOAP notes, SOAP notes, SOAP note, occupational therapy documentation

3/29/2021

Occupational Therapy SOAP Note

Occupational therapy SOAP notes, an overview of SOAP notes; questions to ask when writing each section; the do’s and don’ts of writing soap notes; the benefits of using SOAP notes in occupational therapy; and an example of an occupational therapy SOAP note will be covered in this post. The SOAP note method of documentation can be an excellent fit for the occupational therapy profession. Why does it work well for OTs? We are always looking at the big picture. SOAP is an acronym that stands for subjective; objective; assessment; plan. These are all important components of occupational therapy intervention and should be appropriately documented. Using a SOAP note format will help ensure that no essential element of therapy is left undocumented.

CPT codes occupational therapy, 8 minute rule

3/15/2021

CPT Codes Occupational Therapy

CPT codes occupational therapy, including 8-minute rule; 20 common CPT codes for occupational therapy (e.g., CPT code 97100) and resources will be covered in this blog.

Teletherapy e-book

Get latest articles right to your Inbox

    Blog Categories
    Resources
    Teletherapy
    Law
    Telepractice
    Marketing
    Getting Started
    Press
    Behavioral Therapy
    Insurance
    Case Studies

    Latest Posts

    • Occupational Therapy Goals

      Tuesday, April 6, 2021

      Occupational therapy goals and how to create excellent occupational therapy goals; SMART goals; examples of goals with all of the necessary components; and do’s and don’ts for writing OT goals will be covered in this blog post. You have already conducted a full evaluation on your client. Now it is time to come up with occupational therapy goals for their treatment plan. The next step is to take the data you collected and translate it into meaningful goals to pursue in occupational therapy. If you practice in pediatrics, the goal should be also be important to the parent or caregiver. Information about goals comes from the occupational profile, standardized testing, reason for referral, and your analysis of the evaluation. The data you collected in the evaluation serves as baseline data. This will help you track progress for your client, inform intervention choices, and ultimately give your client a foundation for success.

    • Occupational Therapy SOAP Note

      Monday, March 29, 2021

      Occupational therapy SOAP notes, an overview of SOAP notes; questions to ask when writing each section; the do’s and don’ts of writing soap notes; the benefits of using SOAP notes in occupational therapy; and an example of an occupational therapy SOAP note will be covered in this post. The SOAP note method of documentation can be an excellent fit for the occupational therapy profession. Why does it work well for OTs? We are always looking at the big picture. SOAP is an acronym that stands for subjective; objective; assessment; plan. These are all important components of occupational therapy intervention and should be appropriately documented. Using a SOAP note format will help ensure that no essential element of therapy is left undocumented.

    • Goals counseling

      Monday, March 29, 2021

      Goals in counseling and psychotherapy; what makes an effective counseling treatment plan; tips for writing counseling goals and examples of counseling and psychotherapy goals in common treatment areas such as substance abuse, anger management and depression will be covered in this blog. Setting counseling goals is something almost all therapists do with their clients. But why do we do it? Is it because it looks good? Because it structures therapy? To get insurance off our backs? Although there are many different considerations, it is generally understood that making goals is associated with positive treatment outcomes. At least when you do it correctly.

    Download FREE Resources
    Anger Management Worksheets
    Anxiety Worksheets
    Couples Therapy Worksheets
    Self-esteem Worksheets
    DBT Worksheets