Self-Management:
Set and Document Self-Management Goals Collaboratively with Patients
- Identify self-management tools, including the following:
- An action plan that includes goals and describes behavior (e.g., increasing activity by walking 15 minutes, 3 times per week)
- A review of the patient's confidence level (e.g., on a scale of 1 to 10, how confident are you that you can meet your goals?)
- A follow-up plan
- Review the tool with the multidisciplinary team, including all those who will be involved in its use-physicians, nurses, volunteers, promotoras, etc.
- Test the tool with a few patients and revise as indicated. Retest with additional patients and different populations.
- Establish and/or review goals with patients as part of the planned visit and follow-up.
- Assess patients' skill, understanding, and confidence in managing their disease.
- Give patients a copy of goals, and place a copy in the chart.
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