Client will perform what occupation, with what assist level, under what condition, by what time?

Long Term Goals (LTG)

Outcomes/Discharge

• What do you want and need to do by discharge?

Short Term Goals (STG)

Objectives (you may have more than 1 for each LTG)

• How do we get to that long term goal?

• Depends on the setting you are in

Example:

LTG

Client will complete four step stove top meal prep with modified ind. using a walker within 1 week.

STG

Client will retrieve and transport items from refrigerator to stove using walker and small cart with min assist within 3 days.

Source: Gateley & Borcherding, S. (2017). Documentation manual for occupational therapy: Writing SOAP notes (4th ed.).Thorofare, NJ: Slack Inc. ISBN:9781556429712

Play/leisure

• Charlie will engage in pretend play activity with peers for more than 5 minutes with minimal adult facilitation by March 18th. 

Emotional Regulation

Client will independently regulate emotions by using strategies to participate in play activities within 10 weeks. 

• STG: Client will participate in a physical activity with the use of a fidget toy to regulate emotions for engagement in play within 4 weeks. 

• STG: Client will participate in a social story activity for 5 mins before play to regulate emotions within 6 weeks. 

Fine Motor

Client will increase grasping score to be able to improve his self-care skills and fine-motor skills by time of discharge. 

• STG: Client will participate in fine motor activity for at least 5 minutes with moderate verbal cues to increase following directions and grasp within 4 weeks. 

• STG: Client will engage in fine motor activities (books, puzzles) for at least 10 minutes to increase grasp and fine motor coordination within 6 weeks. 

Or:

Client will independently label 10/10 emotions on how she is feeling to participate in school activities within 10 weeks.

• STG: Client will correctly label 5/5 emotions with min verbal cues using the Zones of Regulation within 4 weeks. 

• STG: Client will correctly label 5/10 emotions with min verbal cues using the strategy of Big Problems/Little Problems to effectively participate in regulation of emotions within 6 weeks.

ADL's

Client will complete dressing of UE and LE with min A within 10 weeks. 

• STG: Client will don shirt with Mod A within 4 weeks. 

• STG: Client will don and doff pants and socks with mod A within 6 weeks.

Handwriting

Client will increase motor coordination score with mod verbal cues from low to below average to improve handwriting within 10 weeks.  

• STG: Client will write her name independently 5x staying within 1/2 inch of the lines for handwriting within 4 weeks.

• STG: Client will participate in a fine and gross motor activity for at least 10 minutes with moderate verbal cues to increase handwriting ability within 5 weeks.

Attention:

Client will independently sustain attention for 15 minutes using coping strategies when completing school related activities within 10 weeks.

• STG: Client will participate in activity for at least 10 minutes with min verbal cues using coping skills to stay on task to increase attention span for school activities within 4 weeks.

• STG: Client will participate for at least 5 minutes with mod verbal cues to stay on task for school activities within 2 weeks.

Source: Gateley & Borcherding, S. (2017). Documentation manual for occupational therapy: Writing SOAP notes (4th ed.).Thorofare, NJ: Slack Inc. ISBN:9781556429712

• Important to collaborate with team to understand educational needs and priorities

• Align need with Common Core Standards or state standards and identify target behavior.

• Establish baseline for target behaviors (baseline means the LTG)

• Establish outcome for target behavior (STG goals)

• Determine how progress monitoring data could be collected on target behaviors with all team members and student

Source: Boyt Schell, B., Gillen, G., & Scaffa, M. (2019).  Willard & Spackman’s occupational therapy.  (13th ed.) Baltimore, MD: Lippincott Williams & Wilkins.  ISBN: 9781975106584