Care Coordination Note (Coach, Athletic Trainer, or Team Physician)

(This template documents communication and coordination events about an athlete's status and participation; it is not a clinical encounter note. For required fields not available, enter "Unknown" or "Not verified" rather than leaving blank. Do not infer consent or authorization—if not documented, treat as absent.)

Date/Time of Communication: [Date and time of contact]

Date of Documentation: [Date] (Note "Late entry for [date/time]" if applicable.)

Athlete: [Name, DOB or ID, team/sport]

Author: [Name, credentials, role]

Communication Type: [phone / in-person / email / text / video / case conference]

Participants: [Name — Role, Affiliation for each participant] (Note whether athlete was present; if not, document how athlete was or will be informed.)

Purpose and Authorization

Reason for Communication: [Purpose, urgency, and key question(s) to be answered] (1–3 sentences.)

Governing Framework: [HIPAA / FERPA / contractual / unknown]

Authorization Status: [on file and valid / not on file / expired / not verified] (If valid, note scope and any athlete-requested limits. If no authorization or unclear, state that no PHI was disclosed. If emergency exception applies, document specific threat and minimum necessary information shared.)

Communication Summary

Requested: [Information or decision requested, by whom, and for what purpose]

Shared: [Information communicated to non-clinicians within authorization scope] (Prefer functional/participation guidance over diagnoses unless explicitly authorized. Do not include full clinical notes or sensitive details.)

Received: [Information reported by others with attribution] (Clarify direct vs. secondhand observation. Use direct quotes sparingly for permission boundaries, refusals, or contentious statements.)

Recommendations and Decision

Clinical Recommendations: [Relevant treatment updates, referrals, rehab progression criteria, red flags] (Include only coordination-relevant items.)

Participation Recommendations: [Practice modifications, load restrictions, equipment needs, competition/travel status]

Decision: [cleared / limited / out] — Decision-maker: [team physician / AT per protocol] — [final / provisional pending further evaluation] (If request declined for safety, document rationale at high level.)

Next Steps

• [Action item] — Owner: [Name/Role] — Due: [Date or trigger] — Confirmation: [Method]

(Repeat for additional action items.)

Acknowledgment: [Recipient acknowledged understanding / did not acknowledge] (Include names and date/time.)

Disagreements or Unsuccessful Contact: [Description or "None"] (If applicable, document escalation path, retry plan, or resolution.)

Signature / Credentials: [Typed name, credentials, role, date/time]