A practice worksheet
What would change if your practice saw the whole person?
This review is for a care team looking at one person’s needs. It takes about thirty minutes.
Pick one part of care your team wants to make better. Use these questions to look past the visit. See who needs to be involved. Agree on one change to try.
You can use the worksheet right here. Use a made-up example, or talk about how your own practice works. Keep real patient details in your practice’s own records.
The blanks on this page are for reading. Write your answers on paper or in your own file.
1. Start with what matters to the person
What matters most
People and
belonging
Home, work,
and self
Meaning and
values
Body and
daily life
What is the person trying to do, get back to, protect, or make sense of? It might be comfort, independence, a relationship, work, family, or a sense of purpose.
In a made-up example, a person might say, “I want enough energy to eat dinner with my family.” That gives the team something real to work toward.
Write one sentence: “The person wants to ______.”
2. Look across the whole picture
Use these prompts to catch things you might miss. Let the person decide what they want to talk about.
You do not need an answer in every row. Note the question, who might help, and what the person wants next.
When to look again
The whole picture changes. Look again at these moments.
A new
diagnosis
A change
in health
A change
at home
The person
asks
Near the
end of life
Can our team meet this need,
or who do we bring in?
Then ask about each need you find. Can our team meet this need? If not, who do we bring in? How will we ask the person first?
3. Make the handoff clear
Pick one question your team cannot answer alone. Who can take it on? What do they need to know? How will the person know the handoff happened? Who follows up if it does not?
Write it in plain words: “______ will contact ______ about ______, and ______ will check that it happened.”
4. Look at the work behind the care
A real change needs time, people, a place to write things down, and a way to keep going. Ask who will do the work and when. Ask what training or review they need. Ask what the practice can give.
If money is part of the plan, write down what still needs checking. Keep the care goal in view while you work through the practical questions.
5. Choose one change to try
Keep the first change small enough to watch. You might make one referral handoff clearer. You might add one question about daily life. You might agree on who follows up when a connection is missed.
Fill in these lines as a team:
Use the review in a team meeting or classroom
Start with a made-up example. Ask each person what they noticed from their own role. Compare the handoffs, the questions still missing, and the work it would take to follow through.
The goal is a better conversation and one clear task to try. This worksheet is for learning and discussion. Your practice stays in charge of its own care decisions.
Where to go next
Educational only. Not legal, billing, coding, clinical, or compliance advice. Do not submit patient or claim information through public website forms.