Outcomes for Any Occasion

Outcome assessment tools (OATs) are a necessary part of documentation and patient care. They are used to show patient progress and help practitioners show changes as a result of their treatment interventions. As a tool, using these assessments keeps doctors accountable and ensures appropriate management (whether it be discharge, continued care or referral). Let's review three kinds of assessment strategies and how their integration into the clinical process can raise the bar in patient management.

Standardized Assessments / Goals

The standardized OAT uses close-ended questions to assess a patient's ability to perform tasks or assess their perceived dysfunction. These tools are developed for specific conditions and have been vetted for their likeliness to quantify changes in patient ability.

For example, one question on the Neck Disability Index (NDI) asks how pain affects a patient's ability to drive. Whether they can or cannot drive due to the severity of pain is a significant ADL for many people. This question, along with the nine others on the NDI, can offer a reliable and valid measure of dysfunction.

With standardized tools, a more objective measure becomes available. With objective measures, we can now look at minimum changes necessary to report meaningful differences in terms of patient outcomes. Minimal clinically important difference (MCID) is an estimate of the least amount of improvement to be considered sensible when re-evaluating a patient. These values are important to know, as subtle increases and/or decreases in scores are not likely to be transferable to actual patient outcomes.

Sample Goal: Reduce Neck Disability Index (NDI) from 31/50 to less than 24/50 after six treatments.

Functional Assessments / Goals

Impairments in body function need to be addressed in order to diagnose patients. Yet these impairments also can become part of the outcomes we'll need to show treatment progress. Probably the easiest way to consider these is through the orthopedic or chiropractic exam. Relevant findings from orthopedic tests (for example, positive Kemp's for facet syndrome with early loss of lumbar lordosis during squat) can be later investigated to gauge improvement.

As an orthopedic examination is intended to expose insulted structures, seeing what once was a positive exam as now negative or without other findings can be a dramatic finding for patient improvement. Portions of the chiropractic exam, posture assessment or range-of-motion, for example, can also provide insight into how the body functions and should be considered when writing comprehensive goals.

Sample Goal: Centralize gluteal referral and/or decrease NPRS during Kemp's from 6/10 to less than 2/10 in four treatments.

Customized Assessments / Goals

The customized assessment gets into the "why" of the patient exam. It's determined not with paperwork or tests, but rather by openly listening to the patient. For example, a patient who presents with neck and shoulder pain after 15 years is typical in a chiropractic office. But what is it about today that drove them to be seen? Why haven't they come in sooner? What's changed in their life that has motivated them to take this first step to finally finding relief?

For me, the patient was a 55-year-old first-time grandfather who was having difficulty picking up his granddaughter. The new infant, while weighing less than 20 pounds, was exacerbating a chronic condition in this patient that was negatively affecting his quality of life. We had found his motivation and were able to write the appropriate goal (below).

Sample Goal: Patient will be able to lift and hold 20 pounds for at least 10 minutes with less than 2/10 pain after four treatments.

Put It in Writing (the Right Way)

Finally, each of these assessments needs to be written in a way that makes sense. The pneumonic often used, SMART, asks if goals are Smart, Measurable, Achievable, Relevant and Timed. When you use this pneumonic as a guideline, goal-writing becomes very straightforward.

For all my patients, including those worked up by students, I write at least one of each type of the above goals. This practice reinforces that the details which come from writing these three types of goals, in this way, significantly improve upon the expectations from the doctor-patient relationship. By forcing yourself to write these goals, you'll find more opportunities to meet the patient's need and reveal their expectations to care, ultimately improving your clinic's performance and helping to ensure the most cost-effective services.