Review Material Patient Record Form

Prevention Is Care:
This form can be used as the basis for discussions with patients
about barriers to achieving optimal health and as a checkpoint for
future visits. Information elicited may inform an Action Plan that
can help patients achieve their goals.

Patient Name/ID:
Appointment Date:
Medical Provider:

What topics were discussed with your patient during today’s visit?

❑ Adherence to medication
❑ Reducing risky sexual behaviors
❑ Remaining in medical care

❑ None of these topics (patient refused)
❑ None of these topics (other issues took precedence)
❑ Other

Did you set a goal with patient at previous visit?

❑ Yes

❑ No

❑ No (Today is patient’s first visit)

Was a goal set with the patient at a previous visit?

❑ Medication adherence
❑ Reducing risky sexual behaviors
❑ Other:

❑ Today is patient’s first visit
❑ Attending all medical visits

What is the patient’s progress on previous goal:

❑ No goal set at previous visit
❑ No progress on previous goal

❑ Partially achieved previous goal
❑ Fully achieved previous goal

What barriers (if any) did your patient identify during this visit?
ART Adherence

❑ Experiences side effects from ART
❑ Forgets to take medications
❑ Experiencing treatment fatigue

❑ Forgets to pick up prescriptions
❑ Cannot pay for medication
❑ Other:

Reducing
Risky Sexual
Behaviors

❑ Lacks information about safe sex
❑ Does not have access to condoms
❑ Unaware of PrEP and PEP

❑ Uncomfortable discussing safe sex with partners
❑ Experiencing prevention fatigue
❑ Other:

Remaining in
Medical Care

❑ Feels too sick to attend appointments
❑ Does not believe medical care is necessary
❑ Lacks access to transportation
❑ Other:
❑ Is concerned about seeing family/friends at clinic

Other Barriers

❑ Mental health issues
❑ Homelessness
❑ Substance abuse:

❑ Lack of social support
❑ Financial concerns
❑ Other:

What does the patient state is his or her primary barrier to achieving optimal health?

Did you and the patient discuss a plan to overcome this barrier?

❑ Yes

❑ No

What is the plan (or goal) that the patient agrees to work on before the next visit:
Referrals:

❑
❑
❑
❑

Case management
Partner services
Mental health services
Substance use services

❑ Prevention counseling
❑ Reproductive health planning
❑ Domestic violence prevention services
❑ Food services

❑
❑
❑
❑

Housing services
Financial services
Support groups
Other:

Source: Adapted from Options Patient Record Form

14_PIC_W3_Patient_Record_Form_v11 12-4-13

PATIENT RECORD FORM

Instructions for Providers
This form can be used to work collaboratively with patients to overcome barriers to achieving optimal health with respect
to remaining in medical care, ART adherence, and reducing risky sexual behaviors.
When used in conjunction with the Prevention IS Care Action Plan, this form can serve as the basis for ongoing brief
conversations with patients to help them achieve their health care goals. As barriers are identified, this form helps
providers work with patients to develop strategies to overcome these barriers and negotiate a goal or action plan the
patient can work toward before their next visit.
Throughout treatment, this form (and the accompanying Prevention IS Care Action Plan) can be used to reinforce success,
to negotiate new goals as needed, and to keep patients engaged in their treatment.
Assessing for Success Throughout a Patient’s Care
By using the various sections of this Patient Record Form over several visits, different areas of care can be explored
throughout a patient’s care.
For example, with a recently diagnosed patient it might be most important to focus a brief discussion on probing for
barriers to ART adherence, whereas with a long-standing patient, a review of risky sexual behaviors might be warranted.
Continued use of the form allows health needs to be reevaluated over time, and the treatment plan can be modified
as needed.
Successful discussions often include:
• Simple, open-ended (vs “yes/no”) questions to encourage discussion
“Tell me more about what has changed in your daily routine that makes it harder to remember to take your
medicines?”
• Reflective listening techniques
“You said that you do not like using condoms because you can’t feel as much. If you’re interested, I have some ideas
that might help.”
• Negotiating goals that are realistic and attainable, without confrontation or pressure
• Respect for the patient as an expert in their own health and wellbeing, remembering that each patient is unique in
what motivates them to change
• Working at the patient’s pace
• Negotiating goals that are realistic and attainable.
Sample Segues into Brief Discussions with Patients…
…about adherence: “I know that taking medicines every day is not easy to do. In fact, a lot of my patients struggle
with it. Do you have any ideas for remembering to take your medicines? Would you be interested in talking about
some ways to make that happen?”
…about sexual behaviors: “A lot of people find it very difficult to practice safer sex. What helps you practice safer sex,
or, if you don’t, what stops you from doing so?”
…about remaining in ongoing care: “It’s very important to your health that I see you for all our scheduled
appointments. I’d like to get a sense of whether that will be a problem for you.”
…about ambivalence: “You’ve said that you’d prefer not to talk about these issues today. That’s okay, but I do hope
that we can talk about them at our next visit, because I believe they’re important to your health. Now, is there
anything else that you’d like to talk about today before we finish up?”

www/cdc/gov/actagainstaids/pic/