Goals not met before discharge.....

[Matt8700, RN, EMT-B]

I have a question about care planning.....

when you formulate the plan of care and set goals, do you take into consideration how long the patient will be in the hospital? If the patient is admitted to the med/surg floor and you set goals for them, but they are only there for two days before discharge, what do you do if the goals were not met because there was not enough time? How do you document this? Do you only pick goals that you can complete before the patient is discharged? it is sometimes very hard to predict how long a patient will remain hospitalized so it's not always easy to define goals that will be met in a day or two.

Any help is appreciated!

[Double-Helix, BSN, RN]

When you're writing goals for a care plan, try to set goals that can be met within the time frame of hospitalization. Remember that a goal doesn't have to state that the patient will be back to their baseline or fully functional. For example, if your diagnosis is Activity Intolerance, you may ultimately want the patient to be able to walk independently up and down one flight of stairs. However, if the plan is to discharge the patient to a short-stay facility for rehab, this may not be accomplished during the hospitalization. Instead, your goal should be more attainable- i.e. "Patient will assist with bathing once daily without reporting shortness of breath."

If the patient was discharged without completing a goal, you would document that the goal was "in progress" at the time of discharge and state the plan for completing the goal after discharge. Such as, "Goal in progress at time of discharge. Pt able to ambulate 500 feet with assistance. Plan for in-home physical therapy 3x per week."

[SopranoKris, MSN, RN, NP]

Our care plans have drop down boxes where we can select Completed, Progressing, Not Progressing, On-Going or Incomplete. When we create our care plans, we typically set up the goals with a target date of 3 days from admission, unless we know the patient will be hospitalized longer, then we typically set the date one week from admission. We are required by policy to review the care plans and update the target completion dates every shift. While the system has templates to make creating the care plans easier, we still have to custom tailor the care plan to fit the individual patient.

[HouTx, BSN, MSN, EdD]

Absolutely! Patient care goals should always be based on the anticipated discharge date. In my organization, we use the SMART format. S=specific, M=measurable, A=accountable (patient or caregiver?), R=realistic, and T=time factor. We can't cure world hunger in 2.4 days, right? With few exceptions, the focus should be on the specific illness/problem for which the patient was admitted and ability to maintain/follow-up care after discharge.

Our Case Managers are a vital part of the process. If a specific goal will not be accomplished prior to discharge, they arrange for transitional support such as Home Care afterward.