Paper-based Shared Care Plan Personal Health Record-Template


This is a paper-based version of the online Shared Care Plan PHR. Users can fill in personal health information and contact information including: emergency contacts, Clinician contacts, environmental and dietary information, Hospital and ER visits, medication lists and illnesses, lab test results, immunization lists, and insurance information.


Patients and their caregivers should fill out and maintain possession of this paper-based PHR.

Helpful Tips

  • The paper-based PHR can be used by itself, without an online Shared Care Plan. Or, it can be used to gather the information needed to start the online Shared Care Plan. It can be a left with the patient after the initial training on the web-based Shared Care Plan.
  • For individuals who are willing and able to use the technology or only the paper-based PHR, one-on-one training, practice, and access to technical assistance are needed to ensure the individual can fully navigate and take advantage of all aspects of the tool.
  • Build off of current organizational support resources and include pertinent group and contact information in the tool.

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