Chapter 14
Tools to help you plan and
support self care

 

Appendix 2

Record sheet to plan and describe your progress in supporting self care

Record your discussions, your action plan, your resource requirements and the outcomes that you expect – for your focus on self care of your chosen condition. Use the form below to record evidence that demonstrates you have achieved what you have planned.

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Your prioritised topic for which you will provide self care support

 

 

 

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Your team includes:

 

 

Team discussion

 

 

What you do next includes

 

 

What extra resources might this require?

 

 

The outcomes might include:

 

 

How would you demonstrate that you have achieved your outcomes?

 

 

At a subsequent date record your actions completed and outcomes achieved

Actions:

1

 

 

2

 

 

3

 

 

Other:

 

 

Outcomes achieved (list them and label them in terms of the self care support approach as to whether it relates toPrevention,Await resolution,Relief of symptoms or Tolerate symptoms):

 

Table A2.1: Role and responsibilities checklist
For each task tick the box for each team member who has a role or responsibility – then note your role and responsibilities for the task.

 

Completed by _____________________________________________________

 

Chapter 14 index

 

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