13.C3 Goals in practice: Rehabilitation Plans A

Putting it All Together

Here we bring all the pieces together in a rehabilitation plan

There is an example of a template for writing rehabilitation plans.  The aim of the template is to illustrate how concepts addressed in this training work together.  It provides an example of how the final stage of the SMARTAAR Goal Process using goals in clinical practice. 

Specifically, incorporating SMARTAAR Goals into a rehabilitation plan will demonstrate how:

  • goals form the basis for developing steps and action plans to guide client centred rehabilitation
  • goals can fulfil the purposes of working with the client and in team collaboration
  • steps  and action plans are developed to demonstrate how the client’s goals can be achieved
  • goal achievement can be used to inform clinical reasoning, as well as communication with the client and other stakeholders. 


What is the essence of the structure of a rehabilitation plan?
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ACHIEVEMENT RATINGS for goals, steps and action plan



Structuring Rehabilitation Plans

Goals are frequently documented in written rehabilitation plans that communicate the client’s goals, rehabilitation treatment plans and progress in a single document. 

Rehabilitation plans are, ideally, a document that conveys to all stakeholders:
  • the goals being aimed for
  • the strategies for goal achievement (i.e. steps and action plans)
  • progress being made.

Documenting this information (goals, strategies and progress) should be an essential step in the rehabilitation of all clients. 

An effective rehabilitation plan is in effect fulfilling the AAR of the SMARTAAR goal process – it links Action plans to SMART goals, Achievement is assessed and Reported on to key stakeholders. 

It enables goals to be used in clinical practice and maximise their utility for the client, clinicians and others.

How a rehabilitation plan is structured i.e. what information goes where, can make a big difference to how effectively it meets the purposes outlined above. 


Client generated and Client focused Goals in Rehabilitation Plans

A rehab plan may include a mixture of client generated and client focused goals. 

The number and type of goals identified by clients will vary.  While many clients will identify participation and activity goals, they may also identify some impairment level goals.  For example, a client may identify a few goals at different levels: (1) ‘I want to get back to work by Easter’, and (2) ‘I want to be able to sit at my desk without pain’.  Some clients will identify several goals, some only one or two, and others may need support to identify even one goal.  Some clients need education in what goals are and how to set them. 

Negotiating realistic and appropriate goals can be an important part of the rehabilitation process, as individuals adjust to their level of impairment and disability.

Clinicians often find it is easier to use the SMART goal format to describe impairment level goals, as these can reflect the results of assessments that are frequently completed as part of the assessment process e.g. ‘Jill’s DASS score will improve by 5 points’, ‘Jack’s knee range of motion will improve by 60o’.  In a rehabilitation plan, these are more appropriately described as actions to monitor a client’s progress towards their own goal, rather than goals in themselves e.g. an action will include ‘to monitor changes in Jill’s anxiety using DASS’.  Additionally, more discrete activity goals may also be reported as steps supporting the client achieve their bigger goal. 

The diagram below illustrates the use of client generated and client focused goals in rehabilitation plans.

Example 1: Jill expresses that she wants her ‘life back’. For her, this means she wants to live independently. However, based on assessments, it is considered unrealistic that this goal can be achieved within the next 3 - 6 months.  Jill is assisted to identify and agree to shorter-term goals that are still relevant to her long-term goals, but more useful in supporting the immediate phase of her rehabilitation.  The more realistic goals described in the rehabilitation plan include being able to independently perform all aspects of her personal hygiene and to competently prepare her breakfast.  Whilst Jill may not have initially identified these specific goals, they are still client focused and still relevant to her stated goal of returning to independent living.  Jill was able to agree to these goals as part of her rehabilitation program.

The diagram below illustrates the relationship between Jill’s client generated goal and the two client focused goals that will help her achieve this.


It is important that the goal statement actually reflects an outcome that is meaningful to the client.  Including the client’s name in the goal helps ensure the goal relates to the desired change in the client.  It makes it harder to write goals that relate to the action plans or objectives of the clinician.  A goal statement that reflects Jack’s main priority could be ‘Jack will return to his pre-injury employment as a shelf-stacker’.  However, including the client’s name in the goal statement is not enough by itself to make it client focused.  For example, ‘Jack will learn safe lifting technique’ describes a strategy and is not a client focused goal.


 Template for Rehabilitation Plan Reporting

A rehabilitation plan template has been developed to illustrate key messages addressed in this Module.  It demonstrates how information can be structured to best apply the principles of high quality goal setting identified in this training. 

The information in the template relates to the section describing the client goal, steps and action plan. 
It also documents the relationship between client progress and the need for different types of services over time, whilst still working towards the client’s main goal. 

The information is not intended to replace existing forms, but may be used to inform a review of rehabilitation plan forms by rehabilitation services.

The template is in the next Section 13.B5b 




Elements of the Rehabilitation Plan Template

The template we use in the Module demonstrates the link between the key elements of the plan: the client goal, steps and the associated action plans. 

The client’s goal is the starting point when devising a rehab plan.  The next step is to identify what the client will need to do to achieve that goal.  Finally, the actions that the client, significant others and rehab team need to undertake to achieve the step are listed.

When appropriate, assess the client’s progress towards their goal. 

Achievement is reported on ALL ELEMENTS SEPARATELY - it is recorded in the ‘Achievement’ column next to the goal, each step and each aspect of the action plan. 
Comments are recorded in the ‘Progress’ box. 

Whilst it may appear cumbersome to assess each aspect of the rehab plan, doing this provides useful information about the reasons why a goal or step has not been achieved.  Did an event occur that was not accounted for?  Was an important element omitted from the plan?  These aspects can then be addressed in subsequent rehab plans.

As each impairment often affects multiple aspects of functioning, it is common for the same steps to be part of the achievement process of multiple goals.  Therefore, elements of the action plan may need to be repeated throughout the rehabilitation plan.  This only emphasises the importance of those interventions to all involved.

In the following rehab plan examples, progress towards the achievement of the goal, steps and action plan is reported using the following scale:

Achievement rating


Not achieved


Partially achieved