Interdisciplinary rehabilitation goal plan template with examples
A rehabilitation goal plan template with example shared goals, so every discipline works towards what the patient said matters.
✓Patient's words beside measurable goals
✓Example goal with baseline and target
✓Built-in team review log
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What's inside
Shared Rehabilitation Goals
Discipline-specific Plans
Family and Carer Involvement
Team Review Meetings
Discharge Planning
Therapist Sign-off
Preview · 6 sections
Interdisciplinary Rehabilitation Goal Plan
Patient
Patient ID
Date of birth
Plan date
Therapy
Therapist
Source assessment
Next review
Assessment snapshot
Patient goals in their words
Shared Rehabilitation Goals
Goal
Baseline
Target
Contributing Disciplines
Timeframe
Review
Discipline-specific Plans
Discipline
Focus
Interventions
Frequency
Physiotherapy
Occupational therapy
Speech and language therapy
Psychology / counselling
Family and Carer Involvement
Family carer involvement
Team Review Meetings
Date
Progress Summary
Changes Agreed
Discharge Planning
Discharge planning
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Assessment Snapshot
Give three to five lines from the admission assessment that explain the starting point.
More guidance
Three to five lines from the admission assessment that a reader needs before the goals make sense: the main changes in function, the home situation, and the key risks. Refer to the full assessment by its date instead of repeating it. Anyone picking up the plan mid-episode, such as a locum therapist, should understand the starting point from this paragraph alone.
2
Patient Goals in Their Words
Quote the patient's goals in their own words, then the family's, labelled by speaker.
More guidance
Write what the patient said in quotation marks, in the language they used if that is how they said it, with a translation alongside. Add the family's goals separately and label who said each one. If the patient's communication is limited, record the method you used to find out what matters to them. These words anchor every shared goal, so resist tidying them into clinical language here.
3
Shared Rehabilitation Goals
Write each goal with baseline, measurable target, contributing disciplines, timeframe and review point.
More guidance
Each shared goal is one functional outcome with a baseline, a measurable target, the contributing disciplines, a timeframe and a review point. Measure what the patient cares about: level of assistance, distance, time, number of cues, or how often it happens at home. If only one therapist can move a goal, it belongs in that discipline's plan. Three to six shared goals is usually enough to steer a team.
4
Discipline-specific Plans
One row per discipline: its focus, interventions and session frequency.
More guidance
One row per discipline. Focus names the part of the shared goals that discipline owns, interventions describe what they will actually do, and frequency gives sessions per week and their length. Add rows for nursing, dietetics or social work if they are part of the programme. Detailed discipline goals stay in each discipline's records, tagged with the shared goal numbers they serve.
5
Family and Carer Involvement
Name each family member or carer, what they will learn, and when.
More guidance
Record who will be involved, what they will learn and when. Name the person; “the family” is too vague to plan around. Note practical limits honestly, such as a son who can only come on Sundays or a carer with her own health problems. If a paid attendant will provide most of the care at home, plan their training too, and note the language they understand best.
6
Team Review Meetings
Log each review's date, progress against goals, and any change with its reason.
More guidance
Each row is one team review: the date, a short progress summary against the shared goals, and any change agreed, such as a goal closed, a target adjusted, or a discipline added or stepped down. Write the reason for every change. Someone reading the plan months later should be able to follow how it evolved without opening every session note.
7
Discharge Planning
Start on day one: destination, provisional date, home visit, equipment, training and referrals.
More guidance
Start this section on day one and update it at every review. Record the expected destination, a provisional date, the home visit plan, equipment to arrange, carer training still to finish, and onward services such as community physiotherapy or a day programme. An early, visible plan gives families time to arrange leave from work, move a bed downstairs or hire help.
Interdisciplinary rehabilitation goal plan template with examples: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Assessment Snapshot
From the team assessment dated 5 March: walks 10 m with a quad stick and close supervision; needs help with lower-body dressing; word-finding pauses in conversation; lives with wife and son's family in a first-floor flat (18 stairs, no lift).
Patient Goals in Their Words
“Mujhe khud bathroom jaana hai.” (I want to go to the bathroom by myself.) Mr R., 6 March. Daughter: “We want him to sit with the family for meals again.”
Shared Rehabilitation Goals
Goal 1: Mr R. will walk from bed to bathroom (8 m) at night with a walker and his wife standing by, on 3 nights in a row, by 2 April. Baseline: one person steadying at the hips. Contributing: PT, OT, nursing. Review: team meeting 19 March.
Discipline-specific Plans
Occupational therapy. Focus: toileting and lower-body dressing (shared goals 1 and 3). Interventions: bathroom practice with raised toilet seat and grab rail, seated dressing practice, carer training with wife. Frequency: 5 × 45 minutes a week.
Family and Carer Involvement
Wife (main carer) to join two OT sessions a week from 10 March for transfers and toileting. Son to attend the Saturday PT session for stair practice. Paid attendant starts at home on 1 April; train in week 4.
Team Review Meetings
19 March. Goal 1 progressing: standby help only on 2 of 3 recorded nights. Goal 2 achieved and closed. Agreed: start stair practice; SLT reduced to twice a week.
Discharge Planning
Expected destination: home, ground-floor room at elder son's house. Provisional date: 12 April. OT and PT home visit in week 3. Family to buy commode after OT advice. Community physiotherapy referral at discharge.
Interdisciplinary goal plan vs discipline treatment plan
Interdisciplinary goal plan
Discipline treatment plan
Goals
Shared functional goals owned by the team
Goals specific to one discipline
Starting point
The patient's priorities from the team assessment
One therapist's assessment findings
Updated by
Key worker after each team review
The treating therapist
Length
Usually one or two pages
Varies by discipline
Main reader
Team, patient and family
The therapist and their supervisor
Tips and mistakes to avoid
Do
Number the shared goals and ask every discipline to tag session notes with the goal number.
Agree how each goal will be measured before recording the baseline.
Keep abbreviations out of the goal column; families often photograph the plan and forward it to relatives.
Give each shared goal one lead, who checks progress before reviews and raises a stuck goal.
In healhab, clinics set up their own goal plan template; nothing reaches the family until a clinician reviews and publishes it.
Avoid
Listing each discipline's goals in turn and calling it a shared plan.
Using the discharge date as every goal's timeframe instead of earlier review points.
Changing goals at a team meeting without telling the family or recording why.
Leaving discharge planning to the last fortnight, when equipment and carer training take weeks.
About this treatment plan
An interdisciplinary rehabilitation goal plan sets out the shared goals a patient and their rehab team are working towards, which disciplines contribute to each one, how progress will be reviewed, and how discharge is being prepared. This free template keeps the patient's own words beside the measurable team version of every goal.
After the admission assessment, to set measurable team goals
When discipline goals do not connect to each other
Before a family meeting, to show who does what
At each team review, to log changes and reasons
Read more
On a rehab team, every therapist can write good goals and the team can still pull in different directions. An interdisciplinary goal plan, also called a rehab care plan (in US settings, a plan of care), starts from a few goals the patient cares about.
Write it after the admission assessment and first goal-setting meeting, then revisit it at every team review. The key worker keeps it current, and each discipline adds its own focus, interventions and frequency.
Questions
What is an interdisciplinary rehabilitation goal plan?+
It is the team's plan for one rehab episode: a few shared, measurable goals drawn from the patient's priorities, the disciplines contributing to each, how often the team reviews them, and how discharge is being prepared.
How is interdisciplinary goal setting different from multidisciplinary?+
In a multidisciplinary model each discipline sets and works on its own goals. In an interdisciplinary model the team agrees shared goals with the patient and each discipline contributes to them. This template supports the second.
How many shared goals should a rehab plan have?+
Many teams settle on three to six, each linked to something the patient said matters. That is enough to steer the team without spreading effort thin. More detailed goals sit in each discipline's own plan.
How do we set goals with a patient who has aphasia or memory difficulties?+
Use supported conversation: pictures, written choices, yes/no questions and family input, with help from the speech and language therapist. Record the method in the Patient Goals section, and check the goals again as communication improves.
How often should the goal plan be reviewed?+
At each interdisciplinary team meeting, which is weekly in many inpatient units and every two to four weeks in many outpatient programmes. Log each review in the Team Review Meetings table.
Is a rehab care plan the same as a goal plan?+
Many centres call this document a rehab care plan. Rename the heading to match your centre; the content of shared, measurable, reviewed goals stays the same.
Is there an example of a completed rehab goal plan?+
Each section guide on this page shows a fictional sample entry, using initials only, including a shared goal with its baseline and target. Use it to judge the level of detail. Clinical interpretation is left for your own clinicians to write.
