SMART Goal & Action Plan (Behavior Change)

Date: [Date]

Patient: [Patient name and identifiers]

Author: [Name and role/credentials]

Document Status: [New / Revised / Continued / Completed / Discontinued]

Encounter Type: [primary care visit / telehealth / care management call / AWV / CCM / other]

Prior Version Date: [Date of prior plan] (Only include if Document Status is "Revised")

Revision Reason: [Reason for revision] (Only include if Document Status is "Revised")

Clinical Context

• [Reason initiated or revised]
• [Target condition or risk factor being addressed]
• [Patient priorities in their own words]
• [Patient declined goal-setting today; plan to revisit on specified date/timeframe] (Only include if patient declines)

(2–4 concise bullets. If any element not assessed, state "not assessed today.")

SMART Goal

Goal Label: [Short name for the goal]

Goal Statement: [Patient-voiced "I will" statement specifying: behavior, dose/quantity/duration, frequency, when/where, start date, and target review date] (One sentence in patient voice.)

Baseline: [Quantifiable starting point, or "baseline not yet measured"]

Success Criteria: [How success will be measured; include partial-success thresholds if applicable]

Outcome Goal: [Longer-term target if discussed] (Only include if explicitly discussed; label to distinguish from behavior goal.)

Action Plan & Barriers

Action Steps:

• [Action step with who, when/where, and tool/cue]
• [Additional action steps as needed]

If-Then Plans:

• [If predictable disruption, then alternative action]

Barriers & Strategies: (Use respectful, non-stigmatizing language.)

• [Barrier] → [Mitigation strategy]
• [Additional barrier-strategy pairs as needed]

Safety Constraints: [Behavior-specific safety guidance] (Only include if clinically necessary for this behavior; omit generic safety language.)

(If barriers not assessed, document: "Barriers not assessed today.")

Confidence & Readiness

Confidence (0–10): [Rating] (Use categorical description if patient cannot use numbers.)

Why this number and not lower? [Patient response]

What would move you one point higher? [Patient response]

Importance/Readiness: [Rating and brief rationale] (Include if assessed; otherwise state "not assessed.")

Plan Adjustment: [How plan was revised to improve achievability] (Include when confidence is low. Final plan above should reflect agreed adjustments.)

Follow-up & Accountability

Review Date: [Specific date or timeframe]

Who Will Follow Up: [Name/role] via [phone / portal message / in-person / telehealth]

What Will Be Tracked: [Behavior measure] via [tracking method]

Support Plan: [Who will support and how] (Only include if applicable and patient consents.)

Patient Copy: [printout / portal / AVS / not provided with reason]

Closure Criteria: [Conditions for goal completion, progression, or discontinuation]