PPC goal and alignment phrases offer concise and consistent ways to document what matters most to the patient.

PPC Goal is the result of the health priorities identification conversation with a patient (Step 1). It identifies the ‘Top Priority’ (condition/symptom/barrier) that is in the way of achieving a ‘specific health goal.’

Use this phrase to document the health goal:

“The problem the Veteran wants to focus on is [INSERT TOP PRIORITY] so they can achieve the following goal: [INSERT HEALTH GOAL].”

Example: “The problem the Veteran wants to focus on is: balance (Top Priority), so they can achieve the following goal: garden on a daily basis (Goal).”

PPC Align is an opportunity to document the recommendations, treatments, and care plan the person is willing to do in order to achieve their health goal (Step 2). Essentially, this should be your ‘Age-Friendly Action Plan’ that is based on what matters most to the individual.

Use this phrase to document PPC care alignment:

“Based on the Veterans’ specific health priorities, we made the decision to:”

Example: “Based on the Veterans’ specific health priorities, we made the decision to:

• Mentation – Continue to use CPAP machine to help with sleep and balance
• Mobility – Refer to physical therapy to work on balance, strength and fall prevention
• Medications – Taper gabapentin off over the next 4-6 weeks

There are two ways these PPC documentation phrases can be easily inserted into your CPRS or Cerner/Oracle documentation:

Option 1: Create a personal template (mostly for CPRS users)

You can place phrases into a ‘personal templates’ (we suggest one template for each phrase). These templates can then be inserted into any note that utilizes the PPC to explore ‘what matters.’ View instructions or video on how to create personal templates.

Option 2: Create dot phrases for PPC Goal and PPC Align:

.ppcgoal   “The problem the Veteran wants to focus on is [INSERT TOP PRIORITY] so they can achieve the following goal: [INSERT HEALTH GOAL].”

.ppcalign   “Based on the Veterans’ specific health priorities, we made the decision to: [INSERT PLAN].”

These are available from the national CPRS Booster Dot Phrase Library. View instructions or video on how to find dot phrases using the CPRS templates.

PPC Phrases offer simple, quick and flexible ways to document the work of PPC, no matter the type of clinical encounter, note, clinical location or provider type.

PPC Phrases are compatible with Whole Health and Age-Friendly Templates and help capture your work as a Whole Health, Age-Friendly provider and clinic.

Lastly, using consistent and identical documentation for PPC goals and alignment can improve the ability to capture where PPC is informing Age-Friendly Care and patient outcomes. This is important in the context of VA Electronic Health Record Modernization, helping show the impact of Age-Friendly Care on Veterans.

We have developed dot phrase instructional videos.

• Instructional Video
• Document

• Instructional Video
• Document

Health Factors are VA Electronic Health Record (EHR)-specific data tags that identify the delivery of various clinical services or approaches during Veteran encounters. Health Factors are a useful and important way to showcase the delivery of the PPC approach (both in identifying health priorities AND aligning care) throughout VHA. PPC health factors are linked to Whole Health and Age-Friendly and thus also capture the engagement and delivery of these programs.

• VA-WHS-AFHS-Identify Patient Priorities: if the PPC approach is used to explore what matters and a specific health outcome goal is documented, This is a Whole Health Clinical Practice and Age-Friendly Approach to what matters.
• VA-WHS-AFHS-Patient Priorities Follow-up: if you used the PPC approach to align care around what matters and make recommendations in service of that value and health outcome goal. Reflects the specific practice of PPC as a Whole Health Clinical Care approach, irrespective of when priorities were identified.
• These can be or are embedded into Patient Health Priorities Note (or PPC template) OR can be added from the ‘encountering’ window. Check with your local CAC about how to include these HFs in your notes where you practice PPC.
• Conditions for selecting these health factors: Documenting and capturing what matters, identification of goals and alignment of care

This template provides a concise and consistent way to document the five core elements of identifying patient priorities: values, health outcome goals, symptoms and preferences, and the ‘one thing’ that guides care alignment.

The preference is to use the phrases, but this can be used as additional support for those who need a more structured approach to documentation.

The template can be used within a specific ‘Patient Health Priorities’ note or can be inserted into any note title you prefer.

This note and note template can be used in conjunction with the ‘Age-Friendly 4Ms National Health Factor’ template to help capture your work as an age-friendly provider. Health factors specific to Patient Priorities Care (thus capturing the use of this approach to determine ‘what matters’) are embedded in the Patient Health Priorities template and the Age-Friendly 4Ms template.

Templates can be used in most settings and by most clinical providers trained in PPC. Depending on your clinical workflow, elements of the Patient Health Priorities Note can be inserted into its own ‘Patient Health Priorities Note’ title in CPRS or other existing note titles (i.e., outpatient extended care).

The Patient Health Priorities Note in CPRS provides a helpful, step-by-step framework for how to conduct a health priorities identification conversation. It can be useful for persons new to the PPC approach, but is not mandatory for documenting or capturing PPC clinical encounters. You should still use the PPC phrases for ‘Goals’ and ‘Clinical Alignment’ even if you still use this template.

Get Started:

• Templates for CPRS can be obtained by requesting TXML file from Puget Sound CAC Team by emailing PatientPrioritiesCare2@va.gov.
• Access training on how to use the template and associated factors
• View example ‘Patient Health Priorities’ template