Patient Action Plan (Care Management)

(Use plain language. Address the patient as "you/your." Keep sentences short. Use bullets. Define any medical terms in parentheses the first time you use them. Omit any section that would be empty unless leaving it out could mislead the patient.)

Patient: [patient full name] — DOB: [MM/DD/YYYY]

Plan date: [date]

Prepared by: [clinician name, credentials, and role]

Clinic contact: [primary phone number] ([hours])

Bring this plan to your appointments.

My Goals

(Include only if goals were set during this encounter; list 1–3 goals; write in the patient's voice when possible)

• Goal: [what you will do] — [how much/how often] — Start: [date or "today"] (Confidence [0–10]: [number] — include only if discussed)
• Goal: [what you will do] — [how much/how often] — Start: [date] (Confidence [0–10]: [number] — include only if discussed)
• Goal: [what you will do] — [how much/how often] — Start: [date] (Confidence [0–10]: [number] — include only if discussed)

Next Steps

(Show as a checklist. Sort by urgency with the most urgent first. Combine all tasks: appointments, labs, refills, referrals, equipment, education, forms. Start each item with an action verb. Include who is responsible, due date/timeframe, and how to complete with phone number/location/instructions.)

• [Call / Schedule / Get / Bring / Start]: [task description]. Who: [you / caregiver name / clinic]. When: [due date or timeframe]. How: [phone number, location, or brief instructions].
• [Call / Schedule / Get / Bring / Start]: [task description]. Who: [you / caregiver name / clinic]. When: [due date or timeframe]. How: [phone number, location, or brief instructions].
• [Call / Schedule / Get / Bring / Start]: [task description]. Who: [you / caregiver name / clinic]. When: [due date or timeframe]. How: [phone number, location, or brief instructions].

My Medicines

(Include only if medication management was part of the encounter. If medications were not reviewed or the list may be inaccurate, replace the table with the single line below. Highlight changes with NEW, CHANGED, or STOP. If a change is uncertain, write "Confirm with clinic before stopping" in Notes.)

(Use only if meds not reviewed) Medication list not updated today—bring your medication list or bottles to your next visit.

When to take	Medicine	Why I take it	How much	Notes
[time of day / with meals / as needed]	[medicine name] [NEW / CHANGED / STOP if applicable]	[plain-language reason]	[dose and frequency]	[tips, warnings, or special instructions]
[time]	[medicine name] [NEW / CHANGED / STOP if applicable]	[reason]	[dose and frequency]	[notes]

Warning Signs & Who to Contact

(Select only the most important warning signs relevant to this patient's conditions—about 5–10 total across all tiers. Use simple words; define medical terms in parentheses.)

Emergency – call 911 or go to the ER now

• [emergency warning sign]
• [emergency warning sign]

Urgent – call the clinic today or after-hours line

• [urgent warning sign]
• [urgent warning sign]

Non-urgent – message or call within a few days

• [non-urgent issue]
• [non-urgent issue]

Who to contact

Who	Phone	Hours	Notes
Primary clinic	[phone number]	[hours]	[how to reach care team or nurse advice]
After-hours line	[phone number]	[hours]	[instructions for nights/weekends]
Care manager	[direct line]	[hours]	[name] (include only if applicable)
Emergency	911	24/7	Call or go to the nearest emergency room

Learn More

(Optional. Include 1–3 links to trusted education materials relevant to this plan. Omit section if no resources discussed.)

• [Education resource title]
• [Education resource title]