Personal Health Plan (Whole Health)

Patient Name: [Patient name]   DOB/MRN: [DOB and/or MRN]   Plan Status: [New / Updated / Reviewed]   Author: [Author name/role]   Date Created: [Date]   Date Updated: [Date or N/A]   Next Review Date: [Date]

Patient Participation: [Co-authorship statement noting patient involvement and any family/caregiver participants with names and roles]

What Matters to Me

What matters most right now: [Patient-stated priorities in first-person or direct quotes] (If the patient declines or is unable to articulate today, enter: "Not discussed today; revisit at next visit.")

Mission, Aspiration, and Purpose (MAP): [First-person MAP statement beginning with "My mission is..." or similar] (If not articulated today, document an explicit deferral statement rather than inferring values.)

Whole Health Assessment

(Include this section only if formal assessment inputs are available; otherwise omit entirely.)

• Assessment sources used: [Personal Health Inventory / interview / prior notes / screening tools]
• Self-rated well-being scores: [Physical: score] ; [Mental/emotional: score] ; [Day-to-day life: score] (Include only if available.)
• Strengths and assets: [What is going well, protective factors, prior successes]
• Challenges and barriers: [Time, finances, transportation, pain, fatigue, mood, readiness, or other factors affecting follow-through]

Health Concerns and Priorities

(Include this section when linking clinical concerns to goals or for care management billing; otherwise omit.)

• Patient-identified concerns: [Symptoms, functional or quality-of-life concerns relevant to goals]
• Clinically relevant active problems: [Only problems directly impacting current goal-setting]
• Link to MAP and goals: [Brief statement connecting top concerns to what matters and planned goals]

Goals

Long-Term Goals (6–12 months)

(Document 1–3 meaningful outcomes. Use the patient's voice when feasible. Remove unused items.)

• Goal: [Long-term outcome]   Target: [Date/period]   Why this matters: [Patient-stated reason]
• Goal: [Long-term outcome]   Target: [Date/period]   Why this matters: [Patient-stated reason]
• Goal: [Long-term outcome]   Target: [Date/period]   Why this matters: [Patient-stated reason]

SMART Goals (Active)

(Limit to 1–3 active goals. Use first-person "I will…" language. Duplicate or delete blocks as needed.)

• Domain: [Moving the Body / Food & Drink / Recharge / Relationships / Personal Development / Surroundings / Spirit & Soul / Power of the Mind]

  Goal statement: [I will … (specific action with frequency/duration/quantity)]

  Timeline: Start: [Date] ; Review: [Date] ; Target: [Date]

  Progress tracking: [What will be tracked and how]

  Anticipated barriers and workarounds: [Likely obstacles and planned solutions]

  Safety considerations: [Relevant precautions or clinician guidance] (Omit if none.)

Self-Care Domain Plans

(Include only domains with an active goal or discussion from today. Delete all others.)

Moving the Body

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Food & Drink

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Recharge

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Relationships

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Personal Development

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Surroundings

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Spirit & Soul

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Power of the Mind

Current state: [Brief patient report]

Goal reference: [Associated goal(s)]

Patient action steps: [Concrete next steps]

Supports/resources: [Classes, apps, community resources]

Team actions: [Referrals, education, follow-up tasks] (Omit if none.)

Professional Care

(Include when clinician-directed care supports Whole Health goals; otherwise omit.)

• Treatments: [Start/stop/continue decisions with rationale tied to goals; include conventional and integrative approaches]
• Referrals: [Who / What / Why / Urgency]
• Care coordination: [Team roles, assignments, communication needs]
• Shared decisions: [Distinguish clinician recommendations from patient-selected options and shared decisions]

Supports and Resources

• Programs/classes/apps/community resources: [Resources the patient will use]
• Support team: [Professional supports (coach, dietitian, mental health, integrative providers); Personal supports (family, friends, caregiver)]
• Contingency/crisis resources: [Safety plan or crisis contacts] (Include only if clinically relevant.)

Progress Tracking

• What will be tracked: [Patient-reported outcomes and/or objective measures per goal]
• How tracking will occur: [Logs / apps / home monitoring] (If not decided: "Tracking method not selected today; revisit at next review.")
• Next check-in: [Date] ; [in-person / phone / video / portal message]

Goal Status Summary: (Add or remove items to match active goals.)

• [Goal reference]: [not started / in progress / completed / modified / paused]
• [Goal reference]: [not started / in progress / completed / modified / paused]
• [Goal reference]: [not started / in progress / completed / modified / paused]

Revision Note: [Brief summary of what changed and why] (Include only if Plan Status is Updated or Reviewed.)