Health Literacy Universal Precautions Toolkit, 2nd Edition

My Action Plan

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.

UCSF Center for Excellence in Primary Care logo.

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:

Photograph of a woman clutching her head while two children argue in the background. ____ Work on something that's bothering me:
____________________________________
Photograph of a couple on a biking/walking trail. ____Stay more physically active!
Photograph of pill bottles. ____ Take my medications.
Photograph of fruits and vegetables. ____ Improve my food choices.
Photograph of a person seated on a park bench and reading. ____ Reduce my stress.
A cigarette is shown snapped in half. ____ 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)

Icon of a traffic light.
  • 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.

  Mon Tue Wed Thurs Fri Sat Sun
Week 1              
Week 2              
Week 3              
Week 4              
Week 5              
Week 6              
Week 7              
Week 8              

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

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 


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:

Photograph of a woman clutching her head while two children argue in the background. ____ Trabajar en algo que me este molestando:
____________________________________
Photograph of a couple on a biking/walking trail. ____ Mantenerme más activo!
Photograph of pill bottles. ____ Tomar mis medicamentos.
Photograph of fruits and vegetables. ____ Mejorar mis decisions alimenticias.
Photograph of a person seated on a park bench and reading. ____ Reducir mi nivel de estrés.
A cigarette is shown snapped in half. ____ 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)

Icon of a traffic light.
  • 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.

  Lunes Martes Miércoles Jueves Viernes Sábado Domingo
Semana 1              
Semana 2              
Semana 3              
Semana 4              
Semana 5              
Semana 6              
Semana 7              
Semana 8              

¿Encontró obstáculos hacienda este plan? Explique.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Return to Contents

Page last reviewed February 2015
Page originally created February 2015
Internet Citation: My Action Plan. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool15a.html