Goal Attainment Scaling (GAS) Record Sheet

Importance to patient: score Important , Very Important, Extremely important.

Patient Name:………………………… Age……… Difficulty of achieving (professionals): score Not difficult, Minor difficulty, Moderate difficulty, Extreme difficulty
Goal attainment baseline: usually set at some function, or No function, (as bad as it can be)
Hospital No:……………………… Discharge date:…… Goal attainment score: As expected = achieves goal as expected. partially achieved = some improvement but goal not achieved,
same as baseline = no change, a little better = achieved more than the goal, Much better – over achieved goal
Keyworker:…………………………………………….
Patient stated goal SMART goal Difficulty of Baseline Variance

Importance

Achieved
achieving (Describe achievement if
differs from expected)

1  Imp  Not difficult  Some function  Yes  Much better

 Minor difficulty  A little better
 v.imp  No function
 Mod difficulty (as bad as can be)  As expected
 Ex.imp
 Extreme difficulty
Baseline function  No  Part achieved
 Same as baseline
 Worse
Date Set………………… Date ………..…..
2  Imp  Not difficult  Some function  Yes  Much better
 Minor difficulty  A little better
 v.imp  No function
 Mod difficulty (as bad as can be)  As expected
 Ex.imp
 Extreme difficulty
Baseline function  No  Part achieved
 Same as baseline
 Worse
Date Set………………… Date ………..…..
3  Imp  Not difficult  Some function  Yes  Much better
 Minor difficulty  A little better
 v.imp  No function
 Mod difficulty (as bad as can be)  As expected
 Ex.imp
 Extreme difficulty
Baseline function  No  Part achieved
 Same as baseline
 Worse
Date Set………………… Date ………..…..

Baseline GAS T-score: Achieved GAS T-score Change in GAS T Score Date………………………….
P.T.O if necessary
 Goal Attainment Scaling (GAS) Record Sheet
Patient stated goal SMART goal Difficulty of Baseline Variance

Importance

Achieved
achieving (Describe achievement if
differs from expected)

4  Imp  Not difficult  Some function  Yes  Much better

 Minor difficulty  A little better
 v.imp  No function
 Mod difficulty (as bad as can be)  As expected
 Ex.imp
 Extreme difficulty
Baseline function  No  Part achieved
 Same as baseline
 Worse
Date Set………………… Date ………..…..
5  Imp  Not difficult  Some function  Yes  Much better
 Minor difficulty  A little better
 v.imp  No function
 Mod difficulty (as bad as can be)  As expected
 Ex.imp
 Extreme difficulty
Baseline function  No  Part achieved
 Same as baseline
 Worse
Date Set………………… Date ………..…..

Scores of Engagement and Satisfaction

On Admission On Discharge
Patient Engagement Family Engagement Patient Satisfaction Family Satisfaction Patient Engagement Family engagement Patient Satisfaction Family Satisfaction