The patient care provider must document in the patient’s record the patient’s goals, progress toward meeting their goals and expected outcomes related to the use of the items or services provided (Guide pg. 40).
While most of your patients will have ongoing goals, Standard PC.4 is focused on the goals that the patient sets for themselves.
Often, established goals are clinical in nature and designed to meet standard clinical outcomes. PC.4 is designed to more fully involve the patient in his or her own care and progress, determining what personal goals they have with the device you are providing them and helping them reach those goals.
Taking the time to get the patient’s backstory will give you a better understanding of why they have chosen a specific goal(s) and why those goals are important to them. Give your patients control over their success by using patient-centered functional goals in formulating your treatment and follow-up plans.
And of course, everything needs to be documented. All patient goals and expected outcomes related to the use of an item or service needs to be included in the patient’s record (the clinical notes section would be a good spot!).
Keeping track of how your patients are progressing toward their goals and outcomes can serve as motivation and a way for you to determine whether any goals or outcomes should be tweaked or reevaluated. Try using surveys, interviews, evaluations, outcome measures and any other methods you find helpful to directly measure your patient’s progress.
In the end, being compliant with these standards is likely to boost overall satisfaction with the quality of care you’ve provided and ultimately lead to greater success for the patient.