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The Action Plan Form is available in Word (14 KB) as well as an Action Plan Form Example (17 KB).

The 10 Building Blocks of Primary Care

Background and Description

The Action Plan is a tool used to engage patients in behavior-change discussion with a clinician or health coach. Using an action plan, patients set a goal for behavior that they wish to change, and clinicians/coaches engage patients in a discussion of an action plan that can help the patient fulfill the goal. Action plans should be patient-driven, specific, and realistic (patients have a high confidence level of success of the plan).

Instructions

Ask the patient what he/she would like to do to improve his/her health (e.g., physical activity, improving food choices, taking medications, reducing stress, cutting down on smoking, or a goal of their choice). Ask more about specific details and record these details on the action plan form (what, how much, when, how often, where, and with whom). Once the patient identifies a specific action plan, ask the patient to assess his/her confidence level in achieving the action (using a scale of 0-10). If the confidence level is less than 8, ask how the goal can be changed to increase a confidence level of 8 or more.

UCSF Center for Excellence in Primary Care

The Center for Excellence in Primary Care (CEPC) identifies, develops, tests, and disseminates promising innovations in primary care to improve the patient experience, enhance population health and health equity, reduce the cost of care, and restore joy and satisfaction in the practice of primary care.

Copyright 2014, The Regents of the University of California
Created by UCSF Center for Excellence in Primary Care.

All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered and that attribution is given to the UCSF Center for Excellence in Primary Care. These materials may not be used for commercial purposes without the written permission of the Center for excellence in Primary Care.

My Action Plan

DATE: _________

I _______________________________________ and __________________________ have agreed that to improve my health I will:

1. Choose ONE of the activities below:

	____ Work on something that's bothering me: ____________________________________
	____Stay more physically active!
	____ Take my medications.
	____ Improve my food choices.
	____ Reduce my stress.
	____ Cut down on smoking.

2. Choose your confidence level:

How sure are you that you can do the action plan? (if <7, then change plan)

10 VERY SURE 7 SURE 5 SOMEWHAT SURE 0 NOT SURE AT ALL

3. Fill in the details of your activity:

What: ________________________

How much: ________________________

When: ________________________

How often: ________________________

Where: ________________________

With whom: ________________________

Start Date: ________________________

Followup Date: ________________________

Best Way to Follow Up: ________________________

Action Plan Calendar

Draw a O in the box for the days that the action plan was set. If the goal for that day is reached, draw a check √ in the circle.

Did you face any challenges doing this plan? If yes, explain below.

__________________________________________________________________________

__________________________________________________________________________

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Mi Plan De Acción

Fecha: _________

Yo _______________________________________ y __________________________ hemos acordado que para mejorar mi salud, voy hacer lo siguiente:

1. Escoja UNA de las siguientes opciones:

	____ Trabajar en algo que me este molestando: ____________________________________
	____ Mantenerme más activo!
	____ Tomar mis medicamentos.
	____ Mejorar mis decisions alimenticias.
	____ Reducir mi nivel de estrés.
	____ Fumar menos.

2. Escoja su nivel de confianza:

¿Qué tan seguro(a) está usted de poder cumplir con su plan de acción? (si <7, cambie el plan)

10 MUY SEGURO(A) 7 SEGURO(A) 5 UN POCO SEGURO(A) 0 NADA SEGURO(A)

3. Llene los detalles de su actividad:

Qué va a hacer: ________________________

Cuánto: ________________________

Cuándo: ________________________

Con qué frequencia: ________________________

Dónde: ________________________

Con Quién: ________________________

Fecha de comienzo: ________________________

Fecha para revisar el plan: ________________________

Mejor manera para contactario(a): ________________________

Calendario de Plan de Acción

Marque con un circulo "O" los cuadros de los días que fijó para hacer su plan de acción. Si cumplió su meta para ese día, marquelo con una palomita √ dentro del circulo.

¿Encontró obstáculos hacienda este plan? Explique.

__________________________________________________________________________

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