Initial evaluation format

1. Initial evaluation format Dr. Ali Abd El-Monsif Thabet

2. Goals They are intended results of patient management that indicate the changes in impairment, functional limitations and disabilities, and the changes in health, wellness and fitness needs, that are expected as the result of implementing the plan of care.

3. Goals Through documentation of these goals, therapists express their knowledge of patient's specific problems, formulate the prognosis, and provide the foundation for developing an intervention plan specific to the patient's needs.

4. Goals The process of setting goals :-expected outcomes should be emphasized:- First, in establishing goals, the PT makes a professional judgment about the prognosis, that is, the likelihood of functional recovery. The prognosis is a prediction about the future, and depends on a very high level of skill, knowledge, and experience.

5. Goals Second, is a collaborative effort between the therapist and the patient and often the patient's family and other professionals. "Writing Patient-Centered Functional Goals.". That the goals be focused on what the patient wants to accomplish, for goals to be truly patient-centered, they should be relevant to the patient's desired outcomes, not to what the therapist thinks is 'best' for the patient."

6. Goals Third, goals should guide the therapeutic process throughout its course. If rehabilitation is perceived as a journey, goals are a statement of the destination that the patient and the PT are attempting to reach. For goals to function effectively as a guide they should be referred to during every treatment session, and between sessions as the pt implements his program

7. Goals LONG-TERM AND SHORT-TERM GOALS The traditional approach to documenting goals has been to distinguish between short-term and long-term goals. Here the distinction is based primarily on the time course of rehabilitation. For example, a typical long-term goal might be: Patient will walk independently for distances up to 1000 ft outdoors without assistive devices within 1 month.

8. Goals A short-term goal related to this long-term goal might be Patient will walk 200 ft on level surfaces indoors using a quad cane within 1wk. Thus the concept of a short-term goal is that it is an intermediate step toward achieving the long-term goal. This approach can be useful, especially in rehabilitation settings where treatment may continue for an extended period

9. Long term goal Patient will walk independently for distances up to 1000 ft outdoors without assistive devices within 1 month. Short term goal Patient will walk 200 ft on level surfaces indoors using a quad cane within 1wk.

10. Goals WRITING GOALS AT THREE DIFFERENT LEVELS The therapist establishes expected outcomes at three different levels: disability goals, functional goals, and impairment goals. Disability Goals Disability goals express the expected outcomes in terms of the specific roles that the patient wishes to be able to participate in. These goals provide the "big picture” what is the overall purpose of the physical therapy intervention? The disability goal for one patient may be to return to work, for another to be able to care for her children, for a third to be able to go to mosque

11. Goals Functional Goals Functional goals express the expected outcomes in terms of the skills needed to participate in necessary or desired roles. Functional goals are the key component of any goal section and they should never be omitted. For example, a functional goal may be to walk from the bed to the bathroom, to put on a shirt, or to drink from a cup.

12. Goals Impairment Goals Impairment goals express the expected outcomes in terms of the specific impairments that contribute to the functional limitations. For example, an impairment goal may be to achieve 4/5 strength in the quadriceps, increase range of motion (ROM) of the knee flexion to 110°, or improve symmetry of step length during gait, Impairment goals also may be viewed as short-term goals used as benchmarks (steps) on the way to attaining functional goals.

13. Goals These goals are particularly important for patients who may have serious limitations in functional abilities, such as immediately after a stroke or spinal cord injury. Changes in impairments, such as strength, may be the only immediate demonstration of improvement in the patient's status, and they may therefore be more sensitive indicators of progress. The goal of therapy is then for the improvements in impairments to ultimately result in improved functional abilities.

14. Goals LINKING IMPAIRMENT AND FUNCTIONAL GOALS Impairment goals must always be linked to the functional goals in some way. Sometimes therapists link an impairment goal to a functional goal when they are writing the goal. For example, "Pt. will increase ROM R shoulder flexion to 140°/180, so that patient will be able to comb his hair" The increase in shoulder flexion may or may not be an important impairment/ short-term goal, depending on the factors contributing to the functional limitation.

15. Goals A primary reason that such goals often are not useful is that typically more than one impairment contributes to a functional limitation. In the previous example the patient may have a strength deficit in addition to loss of ROM in the shoulder. Thus the patient could attain the goal of improving ROM in the shoulder, but if strength was not improved, the patient would still not be able to comb his hair.

16. Goals In summary, the focus of therapy should be on achieving critical functional goals, and impairment goals should be subordinate to attaining the functional goals. Therefore initial evaluations often will not include explicitly stated impairment goals, but only rarely should the initial evaluation not include explicitly stated functional goals.

17. Goals FUNDAMENTALS OF WELL-WRITTEN FUNCTIONAL GOALS I- Goals are outcomes not processes The single most important characteristic of goals is that they are outcomes not processes. A goal is something that the patient, not the PT, will do. The goal defines an end state, not the process that results in that state.

18. Goals The following is an example of a poorly written goal: Patient will be taught proper precautions following hip replacement surgery. This is not a goal but a plan for achieving the goal. A better, more specific goal would be as follows: Patient will demonstrate proper hip replacement precautions during bed mobility, sitting, and transfer

19. Goals II- Goals Should Be Concrete, Not Abstract One of the most challenging aspects of writing goals is expressing them in concrete terms. The following goal highlights this challenge: Patient will demonstrate increased control during reaching movements

20. Goals This statement is hopelessly general and abstract. What is meant by "control during reaching movements"? Ideally, goals should be stated in terms of an action or functional task that the individual will perform and must include a concretely stated outcome, such as: Patient will reach to pick up a cup to drink

21. Goals III- Well-Written Goals Are Measurable and Testable The goal should be stated in such a way that the measurement or testing procedure is explicit. The following goal is neither measurable nor testable: Patient will demonstrate good sitting balance

22. Goals One of (many) problems with this goal is that it is unclear how sitting balance will be tested. In particular, use of terms such as good, fair, and poor is not recommended because these terms usually imply something different for each person. A better way to write the goal is as follows: Patient will be able to sit unsupported on the edge of a mat table for up to 1 minute Here the goal is stated in such a way that the test is embedded in the goal itself.

23. Goals IV-Goals Are Predictive Setting goals requires therapists to generate a prediction. The goal states that the patient will be able to accomplish something in the future that he cannot accomplish now. The prediction must be feasible and at the same time challenging. The therapist must also set a specific time within which this goal will be reached.

24. Goals The predictions that therapists make in setting goals will therefore not be perfectly accurate because individual patients differ from each other and from the average results in clinical studies. In general, it is better to err on the side of being too optimistic, expecting a bit more from the patients than they may be capable of achieving. If the PT is wrong, then the consequence is that patients do not quite make it, but they are (usually) no worse than if more modest goals had been set.

25. Goals If, on the other hand, the PT errs on the side of being too conservative in patients' goals, the consequence may be that patients do not accomplish what they were capable of. This approach does not advocate unrealistic optimism in setting goals but instead reflects a preference to challenge patients.

26. Goals V- Goals Are Determined in Collaboration with the Patient and the Patients Family Collaboration with the patient and family is the most obvious of the fundamental characteristics of goals and yet is the most consistently violated principle. Too often the therapist develops a set of goals at the time of writing the initial evaluation, but because the patient is not present at the time, the therapist assumes that these are the goals most important to the patient.

27. Goals Even more detrimental to the rehabilitation process is that the patient may not even be told what the goals are, or they are related only in the most general terms. If the goal is for the patient to be able to walk 500 feet in 2 minutes, why not tell him ? in our experience, when patients are aware of the specific aspects of a goal, they often work on it on their own time.

28. Goals A goal has five necessary components: (1) Who will accomplish the goal (Actor). (2) The action that the individual will be able to perform (Behavior). (3) The circumstances under which the behavior is carried out (Condition). (4) A quantitative specification of performance (Degree). (5) The time period within which the goal will be achieved (Expected Time).

29. Goals Essential Components of a Well-Written Functional Goal (ABCDE) Actor who will carry out the activity usually the patient, occasionally family member or other caregiver e.g., "Patient will..." or "Patient's wife will..."

30. Goals Behavior description of the activity (in understandable terminology) e.g., "...will walk..." or "...will transfer..." or" ...will put on shirt..."

31. Goals Condition circumstances under which the behavior is carried out must include all essential elements of performance (e.g., assistive devices, environmental context) e.g., "...in hospital corridor with quad cane..."

32. Goals Degree Quantitative specification of performance examples of quantification: rate of success or failure, degree or level of assistance, time required, distance, number of repetitions, heart rate at end of activity, etc. "...8/10 times successfully..." or "...in 4 minutes..." or "...three blocks..." or "...500 feet..." or "...with increase of heart rate to no more than 110 beats/min..." Qualitative aspects of performance "with effective toe clearance" "while maintaining proper body mechanics"

33. Goals Expected Time:- how long it will take to reach goal ► stated in days, weeks, months, or, alternatively, number of visits e.g., "...within 2 weeks..." or "...within 3 therapy sessions..."

34. Goals All properly written functional goals should include all five components. Thus the following formula can be applied to writing a functional goal: Goal = A+ B + C + D + E Using this formula, the following goal might be constructed: Pt (Actor) will walk (Behavior) on level surfaces with a walker (Conditions) for a distance of 100 ft. in 2 min (Degree) within 1 wk (Expected Time).

35. Goals Thus a wide range of goals can be constructed by mixing and matching the different components. The benefits of this approach are twofold. First, goals will be properly written, that is, not missing any essential components. Second, this approach is designed to encourage functionally oriented goals because the focus is on the patient and the action he will be performing.

36. Goals THE ART OF WRITING PATIENT-CENTERED GOALS: BEYOND THE FORMULA If the writing of good documentation can be said to be an art, then it is in the writing of goals that the artfulness is expressed. The therapist must rise above the formula and create goals, in collaboration with the patient, which will guide the therapeutic process toward the best possible outcome. The key to creating artful goals is to make them "patient-centered." A patient-centered goal is one expressed in terms of specific activities that are meaningful to the patient.

37. Goals The first step is to start with a fairly generic but still acceptable goal: Pt will walk on level surfaces with a walker and min A for a distance of 100 ft in 2 min within 1 wk. The goal can be reformulated so that it is more patient-centered as follows: Mr.\A (A) will walk (B) from his bedroom to his kitchen (C) with a walker (C) and his wife's assistance (D) in 2 min (D) within 1 wk.(E) A simple change makes the goal much more meaningful to the individual.

38. Goals Disability Goals Generally, disability goals can and should be written just as functional goals are written. The difference is that the activity that is the subject of the goal is stated in more general terms than it would be in a functional goal. Disability goals should each have at least four of the five critical components of a well-written functional goal: Actor (A), Behavior (B), Condition (C), and Expect­ed time (E). The Degree (D) may not be necessary when writing disability goals.

39. Goals The following statements are examples of disability goals: Example 1: Pt (A) will return to work (B) as a bus driver (C) able to accomplish all regular duties (D) within 1 month (E). Example 2: Pt (A) will take care (B) of her two children at home (C) without daytime assistance (D) within 2 mons (E). Example 3: Pt(A) will attend (B) school services (C) within 6 wks (E).

40. Goals Impairment Goals Impairment goals are considered optional for most evaluation reports. They should be included only if specific impairment-level objectives will be worked on during therapy. In many clinical settings, referred to as therapy goals or short-term goals.

41. Goals It would not sound incorrect if a goal read "Pt will increase ROM in R knee." It then appears that the patient is doing something specific to increase the ROM. Thus impairment goals are often stated without the Actor (A) explicitly specified, although the Behavior (B), Condition (C), Degree (D), and Expected Time (E) should be included.

42. Goals Some examples of impairment goals: Ex 1:Strength R shoulder flexion (C) will increase (B) to 4/5 (D) within 3 wks (E). Ex 2:Single limb stance on R leg (C) will improve (B) to 10 sec (D) within 2 wks (E). Ex 3: Pain in R shoulder (C) will decrease (B) to 2/10 on VAS (D) within 1 wk (E). Ex 4: Circumference of wound (C) will decrease (B) to 2 cm (D) within 4 wks (E). Ex 5: Passive ROM of L knee flexion (C) will increase (B) to 110° (D) within 3 wks (E).

43. Goals When impairment goals are written, the Assessment section of a report should clearly state that the specific impairments are contributing to the patient's functional problems. For example, if a goal is set to increase shoulder strength, then it should be clearly documented in the Assessment that weakness of shoulder musculature is contributing to the patient's functional limitations. A common pitfall when documenting impairment goals is to not specify the Degree (D). Example :- ↓ pain in R ankle within 2 weeks.

44. Goals DETERMINING EXPECTED TIMES FOR GOALS Determining the appropriate expected time frames for a goal can be particularly challenging. Inevitably, the physical therapist makes an educated guess about how the pathologic condition, medical history, and many other factors will affect how quickly a patient will achieve a goal. Expected time frames are typically written in weeks. In acute care hospital settings, goals can be set in terms of days. Time frames can also be written in terms of number of PT sessions by which they are likely to be achieved (e.g. Pt. will walk 200 ft. in hospital corridor with min A within 6 sessions).

45. Goals Documenting Goals Setting: Outpatient Name: Keisha Brown D.O.B.: 1/9/85 DATE OF EVAL: 2/12/01 Current Condition: 16 y.o. female s/p fx R distal tibia and fx R proximal humerus 1 wk ago 2° to MVA; NWB R LE. DISABILITY GOAL Pt. will attend regular classroom in high school and participate in all activities, including extra-curricular sports, within 4 months.

46. FUNCTIONAL GOALS 1.Pt. will demonstrate proper performance of home program of active exercises within 3 days. 2.Pt. will transfer wheelchair ↔ car using stand-pilot transfer with min A of father or mother within 2 wks. 3.Pt. will use motorized wheelchair independently in school hallways, elevators, and outside paved areas, while effectively avoiding obstacles and keeping up with peers within 2 wks. IMPAIRMENT GOAL 1. Pt will tolerate R leg in dependent position for 30 min within 1 wk.

47. Thank you