How to Write Measurable Patient Centered Goals in the Nursing Process
Nurses and other health care professionals develop a plan of care for each patient under their care. This plan includes short and long-term goals for functional improvement to help the patient regain maximal independence. These goals must be objective --measurable-- to document progress and justify to insurance companies that the treatment is medically necessary. Goals should be patient-specific and focus on skills that the patient wants to improve on.
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Instructions
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Document baseline functional abilities. Progress cannot be measured without having a starting point to work from.
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Interview the patient and ask him what his goals are. Goals should be patient-centered and achievable and will vary based on the patient's functional abilities prior to illness.
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Set short term goals with a time frame for each skill area. For example, a measurable goal for walking: "Mr. Jones will walk ten feet to the bathroom with a rolling walker with minimal assistance in two weeks." An immeasurable goal would be "Mr. Jones will improve his walking abilities."
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Develop long term goals with a time frame for each skill area. For example, "Mrs. Smith will walk a minimum of 300 feet without loss of balance within eight weeks to allow her to grocery shop."
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Assess your patient's progress on a weekly basis and adjust goals as needed.
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References
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