OT Goal Writing Tips for Adults & Older Adults
This post was originally published on February 1, 2016 and was updated on September 2, 2019.
Goal writing is tough. Goal writing correctly and effectively can be even tougher. Especially when you’re a 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 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, also be sure to talk with your CI or manager to determine how your individual setting prefers goals to be written.
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.
Short Term Goal Example
Your patient is currently Max assist at admission for toilet transfers in inpatient rehab, getting OT 5x per week.
In 7 days, patient will transfer to toilet with Mod assist using DME as needed.
The goal is specific because we know exactly what type of transfer we are going to work on.
The level of improvement for short term 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 eval, 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.
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 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 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 eval, so you can set their long term goal to Modified Independent for their toilet transfer long term goal.
With almost 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 write strength/MMT goals, but some therapists do include this along with a functional component.
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.
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.
Don’t forget to also ask your patient for ideas of what they want to achieve. This will help to make your intervention plan as client-centered as you can.
Do you have any additional OT goal writing tips you would add? Please feel free to share in the comments below!
Looking for More Resources? Be Sure to Check These Out!