Personal Health Record-Template


The Personal Health Record’s primary purpose is to empower patients to take ownership over important elements of their medical information and to share this information with the different practitioners they encounter during care transitions. Key elements of the tool include:
  • Patient demographic information; patient medical history;
  • A checklist of activities the patient should complete before leaving the care facility;
  • Patient medication record;
  • Tips on managing health and medications;
  • Designated space to write follow-up questions for health care practitioners, as well as the Transition Coach, and to track follow-up healthcare appointments; and
  • The patient’s stated personal health goal -- what he or she hopes to gain as a result of participating in this program.


Patients, Caregivers, Transition Coaches

Helpful Tips

Sites should feel free to customize the PHR or adapt a similar tool used by their organization. The patient and Transition Coach should begin the process of reviewing and addressing the various components of the PHR, together, during the first visit (typically in the hospital). Use of the PHR throughout the intervention is instrumental in encouraging patients to assume control of their health care.

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