Care Coordination/Case Management Note

Date/Time of Activity: [Date and time of activity] (If documenting after the fact, begin with "Late Entry:" followed by the actual activity date/time.)

Author/Role: [Name and role/title]

Activity Type: [patient contact / caregiver contact / outreach attempt / collateral contact / interprofessional coordination / chart review / other]

Communication Method: [phone / video / secure message / in-person / other]

Reason / Participants

[Brief narrative of reason and participants] (2–4 sentences. Include the trigger for the activity, such as post-discharge follow-up, referral need, missed appointment, patient request, routine check-in, social needs identified, or benefits issue. Identify who was contacted or involved; specify patient status [reached / not reached / declined], caregivers, external agencies, and care team members as applicable. Note interpreter use with language and modality if applicable. If consent for care management or information sharing was discussed or obtained, note briefly here. Use source attribution for key information: patient-reported, caregiver-reported, or externally confirmed.)

Summary and Actions

[Concise overview of coordination focus and current status] (Summarize what occurred during this activity—e.g., referrals, transportation, medication access, housing resources, scheduling, benefits navigation—and note current status. Include barriers identified and how addressed.)

• [Action performed — method] → [Result/status] (Include outcome: successful / pending / voicemail left / awaiting confirmation. Note responsible party for follow-up.)
• [Additional actions as needed] (For referrals or resource linkages, do not mark complete without explicit confirmation.)

Plan / Next Steps

• [Task] — [Responsible party] — [Timeframe/due date]
• [Next planned contact: date and method]
• [Contingency or escalation plan if applicable] (e.g., if unable to reach by [date], escalate to [role/service].)

(Omit sections or bullets that do not apply. Use plain, respectful language and avoid diagnostic conclusions outside your scope.)