OT Goal Writing Tips for Adults & Older Adults

Goal writing in occupational therapy can be tough. Goal writing correctly and effectively can be even tougher. This is especially true when you’re an OT student or new grad occupational therapist. 

This article will help simplify the goal writing process for the adult and older adult settings, such as inpatient rehab, subacute rehab, home health, and acute care.

These goal writing tips will hopefully make writing your goals a bit easier for those of you who have to write them free-hand, as opposed to checking boxes for pre-set goals, since many documentation systems don’t have the pre-set option.

Note: This method is how I write my goals, and these goals are examples of my typical goal writing style, but to play it safe, always be sure to first talk with your CI or rehab manager to determine how your individual setting prefers goals to be written. 

For more on OT goal writing, be sure to also check out the Seniors Flourish goal writing guide, linked below. This 60 page guide focuses on helping you create measurable, client centered and attainable goals for your clients in any adult focused setting. Note: we may receive a small commission for this purchase at no additional cost to you, and we only recommend products that we use and love. 

First Tip: Write SMART Goals

You likely already know that both short term and long term goals need to be objective, measurable and realistic. There are many different formats you can use to make sure your goals include these components.

The SMART method of writing goals leads you through all of the necessities of the goals. This is a widely popular goal setting method in management and in almost every arena where goal-setting is an everyday part of life.

Writing Short Term and Long Term Goals

Short Term Goal Example

Your patient is currently Max assist at admission for toilet transfers in inpatient rehab, getting OT services 5x per week. A short term goal, focusing on ADL transfers, for this patient is as follows: 

In 7 days, patient will transfer to toilet with Mod assist using DME as needed.

This short term goal is specific because we know exactly what type of transfer we are going to work on.

The level of improvement for a short term goal typically should not be written for more than one level of assist to ensure success. An example of this: If my patient is Max assist for toilet transfers at the evaluation, I will not write a short term/one week goal for the patient to be Min assist, instead I will set the goal for Mod assist for toilet transfers to be realistic.

The goal is measurable. We can test to see whether or not the patient is still requiring Max assist after the 7 day period or if they now only require moderate assist.

This is an achievable goal for a typical patient. With experience, you will gain a better feel for what is an achievable goal and what is not. If you are not sure if a goal is achievable, don’t be afraid to ask your manager or another experienced OT on site.

This goal is relevant to occupational therapy and to the patient because all patients in this situation ultimately want to be able to move around safely on their own during their self-care tasks.

The goal is time bound since the goal must be achieve within 7 days.

Long Term Goal Example

You can write a long term goal (this one is again based on a toilet transfer) by modifying the time and assist level.

By discharge, patient will transfer to toilet with Min A using DME as needed.

For long term goals, improvement is typically two levels of improvement for the assist, as seen in the above goal.

Another example: Your patient is Min assist for toilet transfer at evaluation, so you can set their long term goal to Modified Independent for their toilet transfer long term goal.

With any adult setting, you can upgrade the goals if your patient is meeting them early. To play it safe, I typically stick to the two-level rule and update the goals if/when the patient is exceeding them.

It is also very important to keep the patient’s goals functional and occupation-based. Functional goals may include toileting, toilet transfers, dressing (upper and lower body), and bathing-related goals (including tub or shower transfer if appropriate). I personally do not typically write strength/MMT goals in my acute care or inpatient rehab settings, but some therapists do include this along with a functional component. 

Writing Higher Level IADL Goals

For higher-level IADL goals, you can incorporate a meal prep goal, medication management goal, or a community re-entry goal if these IADLs are relevant to your patient.

The community re-entry goal will depend if outings can be facilitated at your location. Your facility will likely have their own preference, and you can learn a lot from looking at your OT coworkers’ goals.

Patient goals should always relate to what will benefit your patient the most and help them achieve their highest level of independence.

Lastly, don’t forget to ask your patient for ideas of what they want to achieve. This will help to make your intervention plan client-centered and the most helpful plan for your patient.

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Do you have any additional occupational therapy goal writing tips you would add? Please feel free to share them in the comments below!

 

Looking for more OT Goal Writing resources? Be sure to check these out!

Adult OT Goal Bank (My OT Portfolio)

Writing Measurable Short and Long Term Goals (Clinical Webinars for Therapy)

Documentation Writing Orientation (Holsman Healthcare)

This post was originally published on February 1, 2016 and was updated on September 2, 2019 and March 30, 2022.