Clemens Health | IHS goal revision decision record
Updated 2026-10-05 | (651) 354-1196

Use actual observations and the person's account. Mark suggested changes as proposals until the responsible team confirms them.

Current goal
What is the goal in plain language?
Illustrative entry: Prepare for a chosen community activity.
Your notes: ________________________________________

Person's view
Does the outcome still matter to them?
Illustrative entry: Still wants to attend but dislikes the long preparation checklist.
Your notes: ________________________________________

Practice evidence
What was actually tried and with what assistance?
Illustrative entry: Several visits covered only part of the list.
Your notes: ________________________________________

Likely barrier
What explanation needs checking?
Illustrative entry: Task may contain too many unrelated steps.
Your notes: ________________________________________

Proposed change
What specific revision should be discussed?
Illustrative entry: Focus on choosing and packing materials.
Your notes: ________________________________________

Observation for review
What would help evaluate that change?
Illustrative entry: Whether the shorter list is available, used and preferred.
Your notes: ________________________________________

Decision and version
Who agreed to what and which instructions now apply?
Illustrative entry: Record team confirmation before treating the revision as active.
Your notes: ________________________________________

Illustrative example
A goal to “prepare independently for all outings” remains unchanged across several reviews. The person says the checklist is too long and mostly covers things they already manage. Notes show that visits rarely reach the part they want help learning. The team discusses a narrower goal about selecting materials for one chosen activity. The next review will examine the short list, actual practice and the person's feedback. The example shows a reasoning process, not evidence that narrowing a goal guarantees progress.

Next step
Bring the person's view and specific practice evidence to a review, then document one clear decision about the goal.

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.