Clemens Health | Service-review decision record
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.

Person’s experience
What does the person want to keep, change or understand?
Your notes: ________________________________________

Agreed versus actual
Which specific examples show how the arrangement is working?
Your notes: ________________________________________

Type of decision
Does the question concern goals, scheduling, staffing, authorization or another issue?
Your notes: ________________________________________

Decision owner
Who can resolve each item, and what further information is needed?
Your notes: ________________________________________

Communication and review
Who receives the agreed change, and when will the pending items be checked?
Your notes: ________________________________________

Illustrative example
A review identifies both missed visits and a learning goal the person no longer wants. The team records a provider coordination action for the visits and a separate goal-review question for the responsible planning team.

Next step
Use the record to follow up on each decision. Confirm changes through the responsible process before presenting a revised arrangement as ready to begin.

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.