Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Personal Action Plan: Helping clients with chronic conditions develop a plan for learning new behaviours.
Name: _________________________________________
Date: __________________________________________
Phone: _________________________________________
 
The change I want to make happen is:
____________________________________________________________________________________________________________________________________________________________
 
My goal for the next month is:
____________________________________________________________________________________________________________________________________________________________
 
Action Plan:
 
The specific steps I will take to achieve my goal are: (include what, when, how, where and how often):
______________________________________________________________________________
 
The things that could make it difficult to achieve my goal include:
______________________________________________________________________________
 
My plan for overcoming these challenges includes:
______________________________________________________________________________
 
Supports and resources I will need to achieve my goal include:
______________________________________________________________________________
 
My confidence that I can achieve my goal is (scale of 0 to 10, with 0 meaning not confident at all, and 10 being extremely confident:
______________________________________________________________________________
 
Reprinted with permission from the Institute for Healthcare Improvement. Available online at http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/Tools.
Retrieved from: Self Management in Theory and Practice: A Guide for Health Professionals. March, 2009.