Care Plan Worksheet

My Care Plan

Name: ______Date: ______

My Health Care Team
Health Team Members
(name of each team member) / Title/Role
(provide brief description of each members role) / Contact information/Notes
Self/Health Manager/
Support Person/
Primary Care Provider (PCP)/
Clinical Staff (RN/LPN/MA)/
Care Manager/
Care Coordinator/
Other Primary Care Team Member/
Specialty Care Team Member/
Community/
Other/
My Plan of Care/Goals
Date Set: / Patient-Identified SMART Goal
(short term/long term) / Action Steps / Tools/Resources / Readiness for Change / Confidence Scale / Follow-Up
Confidence Scale
Not confident / Somewhat confident / Very Confident
Clinical Goals
Primary Care (or Specialty Care) / Chronic Disease / Outcome Goal / Outcome Goal / Outcome Goal / “What if”/Potential Barrier(s): / “What if” Action Plan:
My Current Medication List
Medication Name / Dose / How Often? / Why / Notes / Updated
My Current Problem List
Medical History / Date of Diagnosis / Surgical History / Date of Surgery / Updated

Attach patient flow charts/run charts with patient data around Dx (e.g., A1C, BP, Lipids, weight/BMI, etc.)

Rev. 7/16/2014