Alright, you’ve completed your assessment(s), analyzed the client’s errors or performance, and know how you want to structure your treatment. You have a pretty good idea of what areas you want to work on, so now it’s time to write your goals.
Is this an area you struggle with? Here are some formatting examples to help you improve your pediatric therapy documentation.
The PCC Method
I don’t know if this is actually called the PCC method, I just made it up (clever, right?). It stands for Performance, Condition, Criterion.
- Performance: What the patient is expected to perform.
- Condition: The condition or context for the performance.
- Criterion: How well the patient is expected to perform.
Let’s look at an example below:
This goal is specific, measurable, and easy to read. If a parent read this, they would know exactly what their child was working on. If you happen to be sick one day and another therapist comes in to treat your caseload, that therapist would know exactly how to structure the therapy session without having to review your treatment notes. You can easily tack on a timeline, assistance level, or mastery component if needed.
The COAST Method
Many occupational therapists endorse the COAST method because it’s occupation centered; however, this format can be adapted to any discipline. COAST stands for Client, Occupation, Assist Level, Specific Condition, and Timeline.
- Client: Identify the client.
- Occupation: The occupation the goal relates to.
- Assist Level: The level and type of assistance you are providing.
- Specific Condition: The condition under which the performance is done.
- Timeline: When the goal is expected to be achieved.
Let’s look at another example using the COAST method.
Source: Gateley, C. A., & Borcherding, S. (2017). Documentation manual for occupational therapy: writing SOAP notes. Thorofare, NJ: SLACK Incorporated.
Hopefully these options assist in your goal writing. Just make sure your goals are clearly defined and measurable. For more on goal writing, check out these 4 Questions Pediatric OT’s Can Ask to Make Goal Writing Easier. A well-written goal will make your data collection and your ability to track progress much easier!