Patient goals describe what a person wants care to help them achieve. A useful care-planning conversation connects that priority to a practical next step, the support available and a way to review progress.
VA's personal health planning resources start with what matters in the person's life and invite them to work with the healthcare team on a supporting plan. This is one example of organizing care around individual priorities.
Start with the priority
Ask the patient what they most want help with, then clarify the meaning in their own terms. A statement such as “I want more independence” is a starting point for conversation. It does not yet specify which activity, concern or decision the team should address.
Useful follow-up questions include:
- “What would be different in your day if that improved?”
- “Which part would you like us to focus on first?”
- “What help would make that next step possible?”
- “Is there something in the proposed plan that does not fit your circumstances?”
These are suggested prompts, not a scored assessment. Avoid replacing the person's words with a professional target before exploring what they mean.
Separate the goal from the action
Consider four entries when developing a plan together:
| Entry | Question it answers |
|---|---|
| Patient priority | What matters to this person? |
| Agreed action | What will happen next? |
| Support and responsibility | Who will help, and with what? |
| Review | When and how will the team check whether the plan still fits? |
AHRQ's guidance for shared plans in integrated behavioral and primary care includes short- and long-term goals, action plans, team roles and patient participation. The table above is a practical way to organize those elements, rather than a required AHRQ form.
Make the connection visible
In this fictional example, a patient's priority is to continue attending an important weekly community activity. Several appointments are being arranged at the same time.
A proposed planning note might say: “Patient wants to preserve the weekly activity where possible. Scheduling team will check available appointment times; patient will review the options. Revisit the plan once times are confirmed.”
The activity is the priority. Checking availability is an action. The scheduling team has a task, and the plan has a review point. No clinical result or appointment availability is promised.
For a clinical goal, use the appropriate assessment, clinical plan and team expertise to decide which actions are suitable. Communication about a goal does not authorize a nurse to change treatment independently.
Revisit the plan without rewriting the person's voice
At follow-up, ask whether the original priority still matters and what happened with the agreed action. If the action did not occur, record the specific barrier or unresolved task. Do not automatically describe the goal as failed or the patient as unwilling.
When handing off care, distinguish the patient's stated preference from a clinician's recommendation and from an action still awaiting confirmation. See shared decision-making for comparing options and motivational interviewing for exploring mixed feelings about a change.
Sources
- Build Your Personal Health Plan (accessed 2026-09-17) — VA Whole Health.
- Develop a Shared Care Plan (accessed 2026-09-17) — AHRQ Integration Academy.