Care Coordination/Case Management Note (Pediatric Psychology)

Date/Time of Service: [Date and time]

Mode: [phone / video / secure message / in-person meeting / team huddle / chart review / other]

Location/Context: [clinic / school meeting / inpatient unit / remote / other]

Patient Present: [Yes / No; if No, note who was present and relationship]

Participants: [Names, roles/titles, and relationship to patient—e.g., mother/guardian, school counselor, PCP]

Reason for Contact: [One-sentence summary of the clinical issue or question prompting coordination]

Consent & Authorization

(Include only when contact involves external parties such as school personnel, outside providers, or community agencies. Omit for internal team communications.)

• ROI status: [On file with (entity name), expires (date) / Not on file / Verbal authorization obtained per policy]
• Consent provided by: [Name, relationship, legal authority]
• Scope permitted: [Topics authorized for sharing and purpose]
• (If no ROI exists, confirm no PHI was disclosed and note steps taken to obtain authorization.)

Contact Summary

Information Received: (Attribute all information to sources. Focus on new or decision-relevant updates regarding symptoms, functioning, adherence, school performance, barriers, or strengths.)

• [Source]: [Concise, decision-relevant update]
• (Add additional items as needed; use direct quotes only when material for risk, consent, or treatment goals.)

Information Provided:

• [Psychoeducation, recommendations, or clarifications provided]
• [Documents/materials shared, delivery method, recipient]

Assessment

(Include when the contact has clinical implications beyond information transfer. Omit if purely informational.)

Clinical synthesis: [Working formulation updates; functional impact observations; response to interventions; barriers identified] (Label inferences explicitly and distinguish from verified information.)

Safety/Risk: (Include only if safety concerns emerged during this contact.)

• Risk domain: [suicidality / self-harm / aggression / neglect / exploitation / other]
• Source and immediacy: [Who reported; acuity level]
• Actions taken: [Safety planning; crisis resources; consultation]
• Disposition: [Outcome and next steps]
• Mandated reporting: [Agency contacted; date/time; reference number] (if applicable)

Plan & Accountability

• [Decision or plan change] — Owner: [Name/role]; Due: [Timeframe]; Verification: [How confirmed]
• [Task or coordination step] — Owner: [Name/role]; Due: [Timeframe]
• [Pending information] — Responsible: [Name/role]; ETA: [Timeframe]
• [Follow-up contact] — When: [Date]; Mode: [phone / video / in-person]; With: [Names/roles]
• [Escalation criteria] — If [threshold], then [action]

Signature

Author: [Name, credentials, role]

Supervising clinician: [Name, credentials] (Include if trainee-authored, per local policy.)