Toolkit for Implementing the Chronic Care Model in an Academic Environment

Smart Goal Sheet

Residents were offered aids such as the Smart Goal sheet to assist them in treating diabetic patients.

Internal Medicine Center, Summa Health System Change Team

How Confident am I?

____Very confident Image of a ladder; top of the ladder aligns with very confident, and the bottom aligns with not ready.
____Sort of confident
____Getting ready
____Thinking about it
____Not ready
After you pick a goal, check the place on the ladder that shows your confidence to get started.

Smart Goals for Diabetes

People who pick their own goals with support from doctors and care team do better with long-term diseases. Let's get started!

  1. Pick one goal to complete, or write it in. Only one at a time!
  2. Use the ladder to tell how confident you are to start.
  3. Talk to your caregiver about special help reaching your goal.

Getting Active

  • I will start walking for 10 minutes a day, three times weekly.
  • I will find a friend to walk with and go three times weekly.
  • I will start by walking the length of my home five times daily.
  • I will ____________________________________________________.

My Diet

  • I will switch to diet pop.
  • I will eat three meals a day at about the same times.
  • I will replace one fried meal a day with fruit or vegetables.
  • I will ____________________________________________________.

Checking My Blood Sugar

  • I will check and write down my blood sugar twice daily for 2 weeks.
  • I will ask a friend to help me check my blood sugars.
  • I will find out more about why I need to check my sugars.
  • I will ____________________________________________________.

My Medicines

  • I will finish paperwork to get help buying my medicines.
  • I will write down my medicines, doses, and reason taken.
  • I will learn about how my medicines protect my health.
  • I will ____________________________________________________.

My Daily Foot Checks

  • I will learn how to check my feet and start daily.
  • I will wear shoes or slippers everywhere I walk.
  • I will learn what foot problems I should report to my doctor.
  • I will ____________________________________________________.

A Goal I Can Reach

  • I will ____________________________________________________.

Follow-Up Date: _____________

What happened? (Circle one)       1          2          3          4          5
                                                  Not Started         Halfway              Done

Name: ____________________________________________________

Date Initiated: _____________


Special Help Needed To Reach Your Goal
Group Session on:
  • Diet.
  • Choosing goals.
  • Medicine assist.
  • Diabetic skills.
  • Stop smoking.
Referral to:
  • Diabetic specialist.
  • Dietician.
  • Podiatrist.
  • Eye exam.

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Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Smart Goal Sheet. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.