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6.6 Plan of Care & Orders

Goals and Interventions in WellSky

Documenting goals on a routine visit, meeting them at discharge, and adding or updating one — including the order you need first.

Nursing Updated Oct 1, 2026

Goals are charted every visit — at least two or three of them.

Wound care must be charted against its goal every time it is done, along with any goal relating to why you are seeing the patient that day.

What makes a goal worth having in the first place is on Writing Measurable Goals.

On a routine visit

  1. Update Goals and Intervention (blue button) in the chart for that visit
  2. Click the main goal that was performed during the visit
  3. Click Perform next to the intervention that was done
  4. Click Patient or Caregiver — whoever the goal was performed on
  5. Mark needs reinforcement
  6. Fill in the comment box
  7. Submit
  8. Click Document Progress next to the main goal
  9. Click the percentage
  10. Submit

The comment box is where the skilled reasoning goes. "Performed" with an empty comment tells a reviewer nothing — see Skilled Language.

At discharge

All goals that can be met, should be met.

A goal must be at 90% before it can be marked met.

  1. Document the goal as normal, changing the percentage to 90%
  2. Click the three dots → Update next to the main goal
  3. Goal Met
  4. Continue on the pop-up to confirm

Adding a new goal

An order has to be written first. No order, no goal.

  1. Open the physician order for the patient once it is in the Hot Box
  2. Write the order for the new goal — new wound care, a new teaching need, labs
  3. Update Goals and Intervention → New Goal
  4. Search the goal you need in the pop-up — CHF, venipuncture, wound
  5. Fill in the boxes, deleting any intervention you do not need
  6. Assign → Return
  7. Write the order in the physician order for the updated goal
  8. Sign the order

Updating an existing goal

Also needs an order first.

  1. Open the physician order and write the order for the update — a wound care change, for instance
  2. Update Goals and Intervention → click the main goal needing updating
  3. Discontinue any intervention no longer needed — old wound care orders
  4. New Intervention under Document Progress for that goal
  5. Type it in the pop-up, or use the free text button
  6. Fill in the updated goal → Submit → Return
  7. Sign the order

Free text

Use free text when the main goal or intervention list does not contain what you need to say. It is there so the plan fits the patient rather than the other way round.

The order comes first, every time

Both adding and updating a goal start with a physician order. That is not a WellSky quirk — you can only deliver interventions you have orders for. See Verbal Orders and Clarifications.