Needs
Needs are areas of significant clinical concern identified through clinical assessment which impact a client’s overall health and well-being. In short, they are the main issues to be addressed and why the client needs service. Some examples include Substance Use, Mobility, Communication, and Education/Employment.
Needs and Goals are paired and entered together. When selecting a Need, you must also select a Goal.
Goals
Goals are the sub-categories of Needs and answer the question, “what are the desired outcomes?” For instance, a Need of Mobility may have multiple Goals such as Balance, Endurance, Safe Transfers, etc., each of which would be entered as pairs in separate entries.
When a client’s Need has been determined but the Goal is undecided, you may select the pick-list item ‘To Be Determined’ from the Goal pick-list until a plan is developed.
NOTE: If a clinician identifies the same Need, Goal, or Intervention as another clinician, he or she should communicate with the other involved clinicians to coordinate care. You may also choose to enter your own Need, Goal or Intervention as the details may not be the same as the other clinician’s.
The Details section allows the user to describe the detail of the Goal and make it client-specific. For example, the client’s words may be paraphrased or the clinician may use ‘SMART’ goals. For example, for a Goal of Bathing, the details may be described as “Client will bathe safely and independently at home within 2 months”.
Interventions
Interventions are the details of the services being provided and how the goal will be addressed. Some examples include: Therapy/Counselling, Referral and Follow-up, and Home Support. Interventions are chosen from a standard pick-list. Interventions must be linked to a Goal; hence, a Goal must exist before an Intervention can be created.
When creating an Intervention in the Clinical Care Plan, you can link it to one or more Goals. For example, a Home Support Intervention may address multiple Goals such as Falls Prevention, Bathing or Improve Mood.
Details may be entered to further describe the intervention, which may include specific activities and tasks. For example, if a Goal of Abstinence has an Intervention of Individual Support, the free text details might say “Case Manager will visit with client weekly to discuss treatment plan and progress of AA classes”.
NOTE: A user can only link an Intervention to a Goal that was created by the same team.