5 Reasons You Need to Change Your Plan of Care – Documenting All Goals in a Therapy Session

You Are Doing More Than You Realize!!!

Do you find yourself looking back at your therapist notes and noticing that it seems like the same goals aren’t being targeted session after session? The third reason of our 5 Reasons You Need to Change Your Plan of Care series is simply addressing the goals in therapy, but not documenting them in your daily note.

Sometimes a therapist becomes focused on one or two goals for a child’s plan of care and as a result, may not be as focused on all goals areas. A pediatric patient’s goals can overlap in certain areas. A therapist may actually be working on a goal area, but may not realize they are targeting that goal because they are too focused on another area. They may have hit all the child’s goals with just one activity, but it didn’t occur to them at the time of documentation because the therapist was focused on one particular outcome.

Let’s take a look at an example: A child may have an articulation goal (targeting /k,g/) and a language goal (answering “wh” questions). The therapist may be targeting productions for /k,g/ and as they do that, they are engaging the child in answering “what” questions. The therapist may be so attentive to the articulation goal that they don’t realize they are also targeting the language goal and as a result, they don’t document it.

A good therapy session looks effortless; the child is having fun doing the therapeutic activity, making it easy to overlook the goals that have been targeted. So, it’s important to take a step back, consider the session as a whole and document the patient’s progress in all areas.

For more information, check out Pediatric Developmental Therapy’s Working Therapist Podcast titled, “5 Reasons You Need to Change Your Plan of Care.”