Intent:
The person being assessed is an important member of the health care team. It is essential to ask him/her to identify what his/her goals of care might be. By doing so, the person is encouraged to be an active member of the team. This can also be a starting point to develop a person-centered plan of care or services.
Process:
Use this box to document outcomes that the person hopes to achieve as a result of receiving services. These outcomes may relate to almost anything, including improved functional performance, a return to health, increased independence, an ability to maintain community residence, improved social relations, etc.
Talk to the person and phrase your questions about goals of care in the most general way possible. For example, ask: How can we help you? Why are you getting (or applying for) services? What benefits do you expect to get? What changes in yourself do you hope will occur? Encourage the person to express personal goals in his/her own words.
Some persons will be unable to articulate a goal, expected outcome, or even a reason for seeking services. They may say they do not know or that they are getting service at the request of a relative. All of these are reasonable responses. Do not make inferences about what you or other clinicians believe should be goals of care. Follow your usual agency policy if the person asks you for clarification on what they might expect from services.
Coding:
Use the large (“open text”) box to record the person’s verbatim response. Enter “NONE,” if the person is unable to articulate a goal of care.