Clemens Health | IHS goal-review notes
Updated 2026-10-05 | (651) 354-1196

Download this editable worksheet, add your notes, and bring it to the relevant planning conversation. Leave unknown details blank and identify who can confirm them.

Goal under review
What was the agreed goal and starting point?
Your notes: ________________________________________

Observed example
What happened, where, and with what tools or assistance?
Your notes: ________________________________________

Person’s view
What felt useful, difficult, or no longer important to them?
Your notes: ________________________________________

Proposed adjustment
What does the team want to discuss changing, and why?
Your notes: ________________________________________

Decision and owner
What is agreed, what is pending, and who will follow up?
Your notes: ________________________________________

Illustrative example
A person uses their checklist at home but finds it hard to use in a busy shop. The team records the difference in setting and asks what format would help. It does not label the skill mastered or failed based on one setting alone.

Next step
Bring these notes to the provider’s review conversation and include the case manager when authorization or service goals need reconsideration.

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.