Development of a Clinically Feasible Process for Identifying Individual Health Priorities

Aanand D. Naik, MD; Lilian N. Dindo, PhD; Julia R. Van Liew, PhD; Natalie E. Hundt, PhD; Lauren Vo, MS; Kizzy Hernandez-Bigos, BA; Jessica Esterson, MPH; Mary Geda, BN, MSN, RN; Jonathan Rosen, MD; Caroline S. Blaum, MD, MS; Mary E. Tinetti, MD


J Am Geriatr Soc. 2018;66(10):1872-1879. 

In This Article


Supplemental Table S2. Patient Priorities Electronic Health Record Template

Current Function and Support:

83 years, Resides in own home with spouse, independent with activities of daily living

Health trajectory (Current understanding of how health will likely change over the next few years): I hope better, less tired

Matters most (Values):
Connection with others—granddaughter, spouse, grandniece, grandnephew, family Mobility—be able to get up and get out

SMART Health Outcome Goals

  1. I want to be able to go out shopping with my niece and nephew—current fatigue and weakness are a barrier to this

  2. I want to continue to be able to play scrabble with my granddaughter—does not perceive any barriers to this

  3. I want to visit my grandniece and nephew each week—current fatigue and weakness make this difficult

Helpful care: The medications, self-management tasks, clinical visits, tests, or procedures, that I think are helping me most with my health goals and I can do them without too much difficulty

  1. Zolpidem Tartrate is very helpful at night

  2. The Voltaren Gel is helpful with my knee pain

  3. I start physical therapy for gait and balance improvement next week

Difficult or bothersome care: The medications, self-management tasks, clinical visits, tests, or procedures that don't think are helping my goals and are bothersome or too difficult for me. I would like to talk with my doctor about whether these are helping my goals. If not, can I stop them or cut back? If they are helping, is there a way to make them less bothersome or less difficult?

  1. I'm waking up with a hot flash, I don't know if it is the medications

  2. I don't want a knee replacement even though it is terrible going up and down the stairs, I am too worried about recovery

  3. I want to know if my medications are making me feel so tired and weak

Specific ask (One Thing): The one thing I most want to work on is (fill in a health problem that you think is keeping you from achieving your health outcome goal OR the healthcare task that is most bothersome or difficult) so that I can do more of (fill in health outcome goal).
I want to get off some of these medications that are making me feel tired so that I can go out shopping with my niece and nephew
Priorities Facilitator: Phone/Email: