The following page will open and allow you to choose each area and document the patient’s Current Problems, Goals, Objectives and Interventions. Add Status for each area in numerical order starting with a Current Problem if one is included. Click on Add Problem.
Choose the Problem, Dimension or Area, Action, type in any Notes. Then click on Save.
Then Choose Add Goal and add what the patient reports is their Goal for this Area or Dimension, (you may skip the stages of change drop down if your agency allows) add the target date for achieving the goal, select the Problem (if included) and choose Save.
Goals should include statements in the patient’s own words and you can specify if this is a strength or a need with the check boxes.
Next, choose the Add Objective button to add a measurable step that is required to achieve that goal and maintain or effect change in the patient’s current status.
You also have the option of editing or deleting the objective.
Next choose Add Interventions button where you can specify the action needed as well as the frequency and duration.
Continue to add each Area or Problem and when the recovery is completed you can choose Print on the right side and preview the patient’s plan.
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