Care Decision Instruments

Version of 25 September 2026. If your printout carries an earlier date, check what changed before relying on it.

A demonstration, made for no one real. Not medical advice.

A demonstration of the kit with an invented person: the records and the words on these pages were made up. It is not medical advice and it decides nothing. Nothing typed into these pages leaves this browser, and on this copy Send goes nowhere.

Who does what

The person who made these pages is a care systems liaison: they work on the records and the questions, and the clinicians named in these pages do the medicine. Nothing here is medical advice: no diagnosis, no treatment advice, no medicine changes. They help you gather your own records, put your own history in one place, write down the questions you want answered, and prepare one page to hand to each clinician. They do not call your clinicians or sit in your appointments; the kit is built so that you do. They work for you, not for any hospital, insurer or doctor (the scope the field certifies as independent patient advocacy). Where AI tools were used to organise or review material, your names were removed first, the pages say what came from where, and those tools are not medical advice either. Everything here is yours: you decide what goes to whom, and you can have all of it back or deleted at any time.

This kit is for visits, not emergencies. A fall with a knock to the head, new confusion, chest pain, trouble breathing, or a reading past the number your clinician gave you (the sitting number the practice wrote on her card): call the clinic today, or the emergency number.

Written with AI, and read against the records. In a real kit these pages are drafted and drawn with AI from the records they cite and the family's own words, and every page is then read against those records by the person who made it. On this demonstration there are no records: every name, date, medicine and reading was made up. The records a real kit cites can themselves be wrong or out of date, and only that person's clinicians can tell them so. Nothing here is medical advice, and nothing here decides anything.

Written with AI, and read against the records. In a real kit every page is read against the records it cites. On this demonstration nothing is real: the person and every record were made up.

Written with AI, read against the records. In a real kit; on this demonstration the person and the records were made up. The full note is under Who made this.

This is a demonstration of the kit with an invented person, Marguerite. Every name, date, medicine, reading and letter on these pages was made up; nothing here is about anyone real, and nothing here is a record a clinician has seen. The kit is made by a care systems liaison, who works on the records and the questions while the clinicians do the medicine: no diagnosis, no treatment advice, no medicine changes. A kit for a real person carries no names.

Four tools built from one shared set of decisions, so they can never disagree: the decision board (who owns what), the mind map (the shape of the whole thing), the interaction chart (why the conditions must be considered together), and the algorithm (the gates before any step). The red dashed marks are deliberate: they show what nobody has answered yet, and they are the most important marks on these pages. No single specialty can see the whole picture from inside its own room; these pages exist to put the whole picture on one desk.

This is the family's working understanding. Please correct anything wrong.
1

The decision board

One card per decision, never per body part. Each card names its question, its single coordinator, and its status. A coordinator is a named human with a phone number; a specialty is a placeholder, not an owner. Fill the red lines in ink as answers arrive.

unowned / unanswered asked, waiting answered, dated
To write, before the next appointment

G0 · What is all this for?

The first goal in the patient's own words, and under it what must not be lost while it is worked on. Every gate in the algorithm is tested against the written sheet.

Owner: the patient and the family. Nobody else gets a vote on this one.

Unowned

D1 · Who holds the whole list?

Which clinician holds the list of every diagnosis, medicine and open referral, and keeps it current? If the answer is nobody, that is the first finding.

Owner: name ______________ · phone ______________

Due: next primary care visitTemplate: primary care bundle
Asked, waiting

D2 · Which results already exist?

Every test the family knows was done, and where its result sits. Retrieval is free and answers half the questions; a new order is the last resort.

Owner: the family, with the records office ______________

Due: before any new test is orderedTemplate: records request
Unowned

D3 · The open referral

A referral made and never completed: who made it, where it went, what stopped it (insurance, closed panel, a fax to nowhere), and who re-sends it.

Owner: the referring office ______________

No light currently lit

D4 · Is the proposed step safe on the whole picture?

Before any procedure or new medicine: has anyone looked at the combinations, not only the single diagnosis in front of them? Which named evidence would turn each gate green?

Owner: the clinician proposing the step ______________

Consulted: every clinician on the listTemplate: second-opinion cover sheet
Blocking every plan

D5 · The events, read together

The emergency and hospital events in one list: what was written each time, what was found, what changed. Six visits on one page are a pattern; one at a time they are six isolated visits.

Owner: primary care, with the family keeping the list ______________

Due: before the next visitTemplate: events list
2

The mind map

The same decisions as a picture. Reading rule: a red dashed shape is a question nobody owns yet; amber is asked and waiting; green is answered and dated. The map is finished when nothing on it is dashed.

The patient G0 What it is for D1 Who holds the list D2 Results that exist D3 The open referral the first goal must not be lost the medicine list the referrals where each sits one release form what stopped it who re-sends
Four decisions around one person. Redraw with the real branches as the intake fills; the map is finished when nothing on it is dashed.
3

Why the conditions must be considered together

Each row is a collision between conditions, because the risk lives in the combinations, not the diagnoses. ● changes what can be done. ◐ changes how it is done. ? means nobody has looked yet.

The collisionWeightAffectsWhose question, and status
Condition A + medicine B (write the pair)●
the proposed step
Which clinician looks at the pair, not the parts? Not yet asked.
Two medicines from two prescribers who have not spoken◐
every dose change
The pharmacist's review; primary care to hold the reconciled list.
A symptom that belongs to two specialties at once?
the diagnosis
Who keeps the list across both? Ask both, in writing, the same week.
Falls or near misses + anything that lowers pressure or alertness●
safety at home
The weekly measures on the Companion are the evidence; bring the table.

The stacks a table cannot hold: write the three-way combinations here as they emerge. Date and source every cell as it gets answered.

4

The algorithm

The plan as a flowchart. Diamonds are gates: no one proceeds through a diamond on a feeling, only on the named evidence. Print this page and circle today's diamond.

The written goal (G0) Gate 1Is the list held by someone? No: D1first Gate 2Have the existing results been read? No: D2retrieve Gate 3Has anyone looked at the combinations? No: D4ask The step, tested against G0
Three gates before any step. Nobody passes a diamond on a feeling, only on the named evidence. Replace the gates with this person's real ones as the plan forms.
5

Templates: living documents

Every ask in this kit, pre-written, lives on the Letters and Worksheets page, where each document can be filled in directly, downloaded as a Word file, or printed to a clean PDF, and edits save privately in the browser. Each decision card above links straight to its document. Keep copies of everything sent.

The kitchen table sheetThe first goal in the patient's words, and what must not be lost.
Records requestOne form, every office; retrieve before you reason.
Primary care bundleThe four requests, one portal message.
To a specialist, before the visitOne page a week ahead: the fear, the three questions.
Second-opinion cover sheetThe reports first, then the three questions.
Events listThe emergency and hospital events on one page.
Pharmacy call-around scriptGentle scouting questions, no patient named.
Master medication listOne page, every appointment, built from the bottles.
+

Links and resources

The CompanionAppointments with their questions, the pain diary, the weekly measures, what keeps them themselves.
Clinician one-pagersOne printable page per clinician: their questions, nothing more.
Medicare home health coverageWhat to ask for at every discharge: doctor-ordered, Medicare-certified home nursing, therapy and aide visits when the person qualifies as homebound.
Area Agency on Aging locatorThe single front door in every US county: caregiver respite and support, benefits screening, local referrals.
Patient Advocate Certification BoardWhat an independent patient advocate is and is not; the credential to consider if this becomes work.

A demonstration kit. The method and the tools are real; the person is invented.

Saved on this device. Not yet sent since your last change. In a real kit, Send goes to the family's private form. This demonstration sends nothing.