COT standard for SNOMED CT subset: Goals of occupational therapy intervention Supporting occupational therapy practice and record keeping College of Occupational Therapists

July 2014

First published in 2014 by the College of Occupational Therapists Ltd 106–114 Borough High Street London SE1 1LB www.cot.org.uk Copyright © College of Occupational Therapists 2014 Last update: 09/07/2014 Author: Chris Austin All rights reserved, including translation. No part of this publication may be reproduced, stored in a retrieval system or transmitted, by any form or any means, electronic, mechanical, photocopying, recording, scanning or otherwise without the prior permission in writing of the College of Occupational Therapists, unless otherwise agreed or indicated. Copying is not permitted except for personal and internal use, to the extent permitted by national copyright law, or under the terms of a licence issued by the relevant national reproduction rights organisation (such as the Copyright Licensing Agency in the UK). Requests for permission for other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale, and any other enquiries should be addressed to the Research and Development department at the above address. Whilst every effort is made to ensure accuracy, the College of Occupational Therapists shall not be liable for any loss or damage either directly or indirectly resulting from the use of this publication. Page 2

Contents

1. Introduction .......................................................................................4 2. Goals of occupational therapy intervention ........................................6 3. Development approach .....................................................................7 4. Integration into SNOMED CT ............................................................8 5. Implications for practitioners ..............................................................8 6. Implications for educators .................................................................9 7. Maintaining the subset ......................................................................9 8. Terms for Goals ................................................................................9 9. References ......................................................................................21

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1. Introduction A series of information standards for SNOMED CT subsets is being developed by the College of Occupational Therapists (COT), the professional body for occupational therapists working in the UK. The standards should be used for all service user care records, whether they are stored digitally or on paper. The standards will complement the College of Occupational Therapists’ Professional standards for occupational therapy practice (COT 2011a) as well as other publications, such as Record Keeping (COT 2010) and Standards for the structure and content of health records: Supporting occupational therapy practice and record keeping (COT 2011b). Occupational therapists practise in many types of generic and specialist health and social care services in the UK. Within these settings, there are variations in the use of language by occupational therapists, both between different areas of practice and across different regions and countries within the UK. Inconsistency in the use of language undermines the value of recorded information for any purpose other than the primary purpose: namely, direct care. Secondary purposes include: service management, commissioning, service data required by government, clinical audit, service evaluation, and clinical research. In addition, inconsistency in language can lead to problems in the usability of integrated digital care records (IDCRs), previously known as electronic care records or electronic patient records. It is important that the headings for data fields in IDCRs are defined nationally to provide the structure and context within which service user information can be consistently recorded, without loss of meaning. The College has published standards for the following SNOMED CT subsets: 

Assessments used by occupational therapists (COT 2009).



Occupational therapy functional observables (vernacular: problems of occupational performance and participation) (COT 2013a).



Goals of occupational therapy intervention (COT 2014).



Outcomes following occupational therapy intervention (COT 2013b).

Two further standards are due to be developed, namely: 

Intents (aims) of occupational therapy intervention.



Occupational therapy interventions.

This information standard comprises terms for the goals of occupational therapy intervention. Page 4

In any one care service, occupational therapists may not need to view and select all goals listed in this standard. However, if occupational therapists across the UK are to move towards greater consistency in their use of language, then all of the terms for goals listed below in table 1 should be integrated into pick lists in every IDCR system. The purpose of pick lists is to facilitate rapid, accurate and consistent recording of information for each service user. Terms can be selected more quickly and accurately from shorter pick lists, and, therefore, the use of a smaller, targeted subset of terms is recommended. The goals pick list could include every single goal term that was ever used by an occupational therapist; however, the pick list would be very large, and searching for the appropriate terms when recording notes every day would be slower, and possibly less accurate or consistent. Consequently, the proposed subset has been restricted to only commonly used terms, and excludes terms that are rarely used in occupational therapy practice. The subset will be reviewed regularly, and terms added or removed depending on feedback from occupational therapist practitioners. Occupational therapists will need to be proficient at searching through the entire SNOMED clinical terms (SNOMED CT) database for goals that are rarely recorded and are not included in the national pick lists. The developers of IDCRs will use the goals subset to develop pick lists that are integrated into all systems used by occupational therapists. The subset may also be used to support ‘as you type’ identification of coded terms, which is similar to the ‘as you type’ option in spell checkers in office suites and other software applications. The national list was developed in 2013 and 2014 with input from members of the British Association of Occupational Therapists (BAOT) and the College of Occupational Therapists Specialist Sections (COTSSs). There is a requirement from April 2015, for all health care practitioners providing NHS funded care in England to code and record key patient data using SNOMED CT terms. The subset ‘goals of occupational therapy intervention’ will help occupational therapists to comply with that mandatory requirement. The coded terms will include key care plan information, such as: problems, goals, interventions and outcomes. There is an expectation that occupational therapists will still be able to record individualised goals as free text, alongside coded goals that are nationally comparable and useful for secondary purposes. An implementation date for the information standard, Goals of occupational therapy intervention, has not been agreed yet. The remaining standards in this series will be published during 2014 and 2015.

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2. Goals of occupational therapy intervention This subset comprises terms used by occupational therapists to record ‘goals of occupational therapy intervention’. A longer and more accurate heading would be ‘goals agreed by service users, involving occupational therapy interventions, and recorded by occupational therapists’. For simplicity, this document refers to the goals subset or simply, OT goals. This document is not written for service users, but is primarily intended for use by the SNOMED CT team at the Health and Social Care Information Centre (HSCIC), and IDCR system developers. It will also be useful to occupational therapists when working with their local IT department to agree sets of coded terms for use by occupational therapists in their care records. Care planning Following assessment, the occupational therapist may need to confirm the overall aim, such as rehabilitation. The aim may be implicit in the care service, e.g. a rehabilitation service. The next step in the care planning process is to identify and agree one or more goals. A goal is a statement of the expected future state of personal ability or performance, sensory functioning, participation in activities, or environmental adaption. A user of health and social care services may have one or more agreed goals, and contact with one or more professions. Some goals may involve the occupational therapist and other staff, and some goals may only involve the occupational therapist. So, the goals recorded by the occupational therapist could also involve input from other staff, or may only require input from the occupational therapist. The HSCIC has been developing a standard for care planning record headings, including the concept of goals, as part of the work to use SNOMED clinical terminology (SNOMED CT) within integrated digital care record systems (IDCRs). HSCIC do not explicitly define the concept ‘Goal’ but do say that: It is possible to express the achievement of a particular physical/mental state as the goal of a care plan by the use of the SNOMED CT® finding context value of ‘goal’. (HSCIC 2014, p24) There is no official definition of the semantic components of goals for service users. However, a goal usually has the following components: 

A subject

Usually the service user, but could be the carer.



A core concept

e.g. dressing, walking, washing, socialising, etc. Page 6



Qualifiers

Level of ability, performance, or participation and

any

requirement

for

supervision,

assistance,

equipment or adaptation. 

Timescale

When the goal is expected to have been achieved.

Since the 1980s, OTs and many other health professionals have been taught that goals should usually be: Specific, Measurable, Agreed, Realistic and Timed (SMART). Recorded goals should also reflect a client-centred relationship with each service user. The core concept relates to an individual’s functioning (e.g. self-care or sensory functioning) or participation in their community. This view of a goal is reflected in the definition quoted in Occupational therapy defined as a complex intervention which says: Goal: A concise statement of a desired outcome or specific result to be attained at a particular stage in an intervention. (College of Occupational Therapists 2003, p54) Examples of goals   

To be able to mobilise independently at home and in the community within 3 months. To be able to return to full time employment within 6 months To be living independently at home within 1 month.

3. Development approach A number of occupational therapists contributed their ideas, references to publications on goal setting, and terms used for recording goals. The British Journal of Occupational Therapy was searched for articles that included specific examples of terms for Goals. The project was also informed by the International Classification of Functioning (WHO 2008), the general Goals subset in SNOMED CT and the draft review of ISO 13940 with the working title: Health informatics — system of concepts to support continuity of care. (ISO 2013) The College of Occupational Therapists (COT) held a national workshop in London on 3 February 2014. Membership included nominees from the COT Boards and Specialist Sections, and experienced occupational therapists with an ongoing commitment to this work through membership of the project’s email circulation list. Page 7

A draft version of the proposed standard, including background, project details, and a draft set of terms for Goals, was circulated in advance of the workshop. Workshop participants and members on the email circulation list were able to contribute to the development of the national set of terms in advance of and during the workshop. Their comments and suggestions informed a revised version of the list of terms. The report of the workshop can be found on the COT website, under eHealth (information management/OT Subset: Goals/) The revised set of terms was circulated to the workshop participants and to OTs on the project email circulation list. Their responses influenced further changes to the list of terms. The final agreed set of terms can be found in table 1. The list of terms will be submitted to the SNOMED team for incorporation into SNOMED CT as a professional subset.

4. Integration into SNOMED CT The College of Occupational Therapists will inform the Health and Social Care Information Centre (HSCIC) that this standard has been published by the College of Occupational Therapists, and was developed with input from across the occupational therapy profession in the UK. The terms will be submitted for integration into SNOMED CT as a professional subset. The integration process is complex, as terms need to be checked against existing terms in SNOMED CT and other resources, including NHS data sets and the NHS data dictionary. Some changes to the proposed terms may be required to ensure compatibility with existing published terms. The revised standard will be published by the College of Occupational Therapists as a professional standard, applicable to occupational therapists working in all four countries of the UK. It will be circulated widely within the profession and made freely available to health and social care IDCR system developers and clinical terminologists. The subset will be reviewed regularly, and terms added or removed depending on feedback from occupational therapist practitioners.

5. Implications for practitioners Occupational therapists will need to become familiar with the list of terms for goals so that they can start to use these nationally-agreed terms consistently in their care records. The list is not intended to include all possible goals, only those that are routinely recorded by occupational therapists in everyday practice. Occupational therapists will need to be proficient at searching through the entire SNOMED CT database when selecting specific goals that are rarely used in occupational therapy practice. Page 8

Occupational therapists may find that they need to record each individualised goal in free-text alongside the coded goal recorded using terms found in SNOMED CT.

6. Implications for educators Educators will need to become familiar with this information standard and plan to incorporate relevant information about the standard in their undergraduate and postgraduate course modules. This will help to ensure that in future practitioners are consistent in their use of nationally agreed coded terms for goals.

7. Maintaining the subset Occupational therapists who use the goals subset when recording coded goals, may find that there are missing terms that they would routinely use in their care records. Some ‘missing terms’ may be relevant only to specific specialist areas of occupational therapy practice, and are not used widely enough to be included in this profession-wide subset. However, other terms will need to be considered for inclusion in the subset. The experience of occupational therapists using this subset to record coded goals for their service users will inform changes to this subset when it is revised. The first regular review will be in 2016–2017

8. Terms for Goals The following subset comprises only the core concepts and not the qualifiers for each goal term. Goal terms will usually be recorded with appropriate qualifiers, such as terms that indicate different levels of functional ability or sensation in relation to the specific goal concept. For example: 

‘Grip strength’ or ‘Range of movement’ will needed appropriate scales that include qualifiers such as ‘within normal range’.



In relation to individual body parts, e.g. pain in ... back, neck, head, upper limb, lower limb, arm, hand, wrist, hip, knee, ankle, foot, etc.

The list below gives the preferred term for each unique goal concept. Each preferred term may be linked to one or more synonyms. Occupational therapists will be able to use synonyms, particularly if the terms are familiar to service users. However, the care record system will also record the preferred term and its unique code, to ensure data is comparable across the country.

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Table 1: Goal terms Mind and body functions Able to feel confident Able to manage own energy levels Able to direct energy Able to sustain energy level Able to stop use of energy Able to be optimistic Able to believe in own skills Able to recognise hope in the future Able to sleep Able to attend Able to respond to stimuli Able to direct attention Able to shift attention Able to divide attention Able to sustain attention Able to remember people Able to remember places Able to remember routines Able to remember future events Able to think creatively Able to identify choices Able to make decisions Able to use decision making strategies Able to problem solve Able to process information Able to analyse information Able to recognise numbers Page 10

Able to understand and use numbers Able to understand and use time Able to understand and use money Able to identify structure and routine Able to establish structure and routine Able to engage in structure and routine Able to maintain structure and routine Able to carry out daily routine Able to identify life roles Able to establish life roles Able to engage in life roles Able to maintain life roles Able to plan Able to use knowledge Able to organise Able to sequence tasks and activities Able to set personal goals Able to plan a journey Able to recognise own emotional pain and distress Able to recognise own emotions Able to manage emotions Able to manage aggression Able to manage anger Able to manage behaviour Able to manage stress Able to manage one’s physical health needs Able to manage one’s wellbeing Able to recognise social cues Able to understand humour Able to use humour Page 11

Able to recognise words Able to recognise letters Able to recognise symbols Able to recognise objects Able to recognise familiar people Able to recognise surroundings Able to undertake a single task Able to undertake multiple tasks Able to recognise own symptoms Able to respond to own symptoms Able to manage own symptoms Able to recognise generalised pain Able to understand generalised pain Able to tolerate generalised pain Able to manage generalised pain Able to recognise pain in body part Able to understand pain in body part Able to tolerate pain in body part Able to manage pain in body part Able to adapt to sensory changes in body part To have improved sensory function Able to recognise pressure care needs Able to understand pressure care needs Able to tolerate pressure care needs Able to manage pressure care needs Able to recognise body temperature Able to manage body temperature To have functional level of stamina Grip strength Range of movement Page 12

Able to reflect on own behaviour Able to appraise own abilities Able to acquire skills Able to learn basic skills Able to recognise impact of self on others Able to be aware of self Able to communicate about self Able to communicate feelings Able to communicate intentions Able to communicate needs and wishes Able to use non-verbal communication Able to initiate conversation Able to maintain conversation Able to take turns in conversation Able to use hearing aid Able to use body language Able to write messages Able to use communication devices and techniques Able to use a non-speech system for communication Able to make phone calls Able to communicate in the event of an emergency

Mobility and Transfers Able to sit down onto bed Able to sit down onto chair Able to sit down onto toilet Able to sit on toilet Able to sit on a potty Able to maintain a sitting position Able to maintain a standing position Page 13

Able to stand from sitting on edge of bed Able to move from sitting on edge of bed to lying in bed Able to move from lying to sitting on edge of bed Able to move in bed Able to move in cot Able to turn onto side in bed Able to get into and out of a bed Able to get up from floor Able to get on and off toilet Able to get in and out of bath Able to get in and out of shower Able to get in and out of a chair Able to get into and out of a car Able to get into and out of a car seat Able to transfer between wheelchair and toilet Able to use stair lift Able to use through floor lift Able to perform wheelchair transfers Able to balance when bending Able to balance when reaching Able to transfer weight Able to weight-bear Able to control head posture Able to pick up objects Able to mobilise indoors Able to mobilise outside Able to mobilise using mobility scooter Able to mobilise using indoor powered wheelchair Able to mobilise using outdoor powered wheelchair Able to mobilise using wheelchair Page 14

Able to initiate walking Able to stop walking Able to manage internal stairs Able to manage external stairs Able to manage internal steps Able to manage external steps Able to mobilise over uneven ground Able to access own home Able to access the garden Able to access where car is parked Able to use public transport Able to drive a car Able to ride a bicycle Able to ride a motorbike Able to find way around a familiar environment Able to find way around a school environment Able to find way around a work environment Able to move items around the home

Self-care Able to tolerate self-care routines Able to anticipate self-care routines Able to assist in self-care routines Able to maintain standard of personal hygiene Able to wash self Able to wash upper body Able to wash lower body Able to dry self Able to dry upper body Able to dry lower body Page 15

Able to shower self Able to bath self Able to wash own hair Able to shave Able to apply own make-up Able to manage medication Able to maintain oral hygiene

Toileting Able to indicate own toileting needs Able to tolerate toileting routine Able to tolerate changing incontinence pad Able to tolerate changing nappy Able to tolerate being cleaned during toileting Able to adjust clothing for toilet Able to clean self after toilet Able to use commode Able to stand at toilet Able to manage menstrual hygiene Able to manage appliance when dressing and undressing Able to manage catheter care Able to manage stoma or ileostomy care Able to manage incontinence products

Dressing Able to dress Able to undress Able to adjust clothing Able to put on footwear Able to take off footwear Page 16

Able to tie shoe laces Able to manage prosthesis Able to take care of clothes Able to choose appropriate clothing Able to organise own clothes

Eating Able to feed self Able to drink Able to cook food Able to prepare drink Able to assist with meal preparation Able to prepare meal Able to prepare snack Able to follow recipe Able to plan meals Able to cater for self Able to transport food and drink

Housework Able to assist with domestic chores Able to have role in domestic chores Able to tidy house Able to clean domestic appliances Able to use domestic equipment Able to use heating appliance Able to clean room Able to clean shower Able to clean toilet Able to clean washbasin Page 17

Able to clean windows Able to clean items at floor level Able to clean items at waist height Able to clean items at shoulder height Able to do washing-up Able to do laundry Able to use washing facilities Able to dry washing Able to make bed Able to do ironing Able to dispose of household rubbish Able to sort recycling Able to manage medication Able to access electric or gas meters

Employment and Education Able to apply for a job Able to apply for voluntary work Apply to apply for an education course Able to participate in school activities Able to participate in classroom activities Able to participate in playground activities Able to participate in self-care at school Able to perform homework Able to use educational facilities Able to undertake voluntary work Able to perform remunerative employment Able to perform work -based activity Able to perform workshop activities Able to use personal computer Page 18

Able to write for lessons Able to write for examinations Able to sign name Able to fill in forms Able to manage personal financial activities Able to budget Able to handle money Able to use credit or debit card

Recreation and leisure Able to identify interests Able to engage in interests Able to engage in a hobby Able to participate in leisure and recreation activities Able to participate in sporting activities Able to perform creative activity Able to perform do-it-yourself activities Able to perform drawing activities Able to perform gardening activities Able to use local amenities Able to use playground Able to use public recreational facilities Able to perform information technology activities Able to use social networking Able to operate media equipment Able to operate mobile phone Able to use games console Able to participate in online gaming Able to assess risk Able to identify risky behaviours Page 19

Able to identify dangers Able to manage risks at home Able to manage risks in the community Able to manage callers to the home Able to close home securely Able to make decisions on safe entry of visitors Able to make decisions on safe information to give over telephone Able to cross the road at formal crossing Able to cross the road away from formal crossing Able to shop at corner shop Able to shop at shopping mall Able to shop in supermarket Able to shop online

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9. References College of Occupational Therapists (2014) COT standard for SNOMED CT subset: Goals of occupational therapy intervention. London: COT. Available at: http://www.cot.co.uk/ehealth-information-management/ot-subset-goals Accessed 09.07.14. College of Occupational Therapists (2013a) COT standard for SNOMED CT subset: Occupational therapy functional observables - problems in occupational performance and participation. London: COT. Available problems

at:

http://www.cot.co.uk/ehealth-information-management/ot-subset-

Accessed 09.07.14. College of Occupational Therapists (2013b) COT standard for SNOMED CT subset: Outcomes following occupational therapy intervention. London: COT. Available outcomes

at:

http://www.cot.co.uk/ehealth-information-management/ot-subset-

Accessed 09.07.14. College of Occupational Therapists (2011a) Professional standards for occupational therapy practice. Revised ed. London: COT. College of Occupational Therapists (2011b) Standards for the structure and content of health records: supporting occupational therapy practice and record keeping. London: COT. College of Occupational Therapists (2010) Record keeping. 2nd ed. London: COT. College of Occupational Therapists (2009) SNOMED Subsets to support occupational therapy: Assessments used by occupational therapists. London: COT. Available at: http://www.cot.co.uk/ehealth-information-management/ot-subset-assessment-tools Accessed 09.07.14. College of Occupational Therapists (2003) Occupational therapy defined as a complex intervention. London: COT. Health and Social Care Information Centre (April 2014) Care planning content clinical configuration and editorial guidance: April 2014 technology preview release. Available from the Technology Reference Data Update Distribution Service (TRUD), ref. NPFITFNT-TO-TOSCI-0051.12 at: http://www.uktcregistration.nss.cfh.nhs.uk/trud3/user/guest/group/0/home Page 21

Accessed 12.05.14. ISO (2013) Health informatics — system of concepts to support continuity of care. Geneva: ISO. World Health Organization (2008) International classification of functioning, disability and health: ICF. Geneva: Switzerland.

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