Clemens Health | Family practice observation log
Updated 2026-10-05 | (651) 354-1196

Use one entry for a real attempt and keep it brief. Examples describe ordinary observations, not a prescribed intervention or a performance target.

Agreed approach
What explanation has the provider checked with you?
Illustrative entry: Use the person's chosen packing list and the agreed reminder.
Your notes: ________________________________________

Opportunity
When did the person agree to try it?
Illustrative entry: Before a planned afternoon activity.
Your notes: ________________________________________

Support offered
What did the family member actually do?
Illustrative entry: Placed the list where requested and gave the agreed reminder.
Your notes: ________________________________________

What happened
Describe actions without a judgment label.
Illustrative entry: Person selected materials and asked where the bag was.
Your notes: ________________________________________

Person's feedback
What did they say or communicate about the attempt?
Illustrative entry: Wanted the list closer to the storage shelf.
Your notes: ________________________________________

Context
What changed the experience?
Illustrative entry: Departure time was earlier than usual.
Your notes: ________________________________________

Next question
What should the provider help clarify?
Illustrative entry: Whether the list location or timing should change.
Your notes: ________________________________________

Illustrative example
A family records that a person did not use the agreed packing list. A closer description shows that the list was in another room and two relatives gave different reminders while they were rushing to leave. At the next visit, the family asks about list placement, a single agreed approach, and timing. They do not describe the event as proof that the person cannot learn. The person's preference to keep the list beside their materials becomes part of the discussion.

Next step
Bring a few observations and the person's feedback to the provider, then leave with a single updated practice agreement.

This is an optional discussion worksheet, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.