Client Communication Note (Phone, Email, or Portal)

Date/Time: [Date and time of communication or attempt] (Required; include time zone if relevant.)

Mode: [Phone / Portal / Email / Voicemail] ([inbound / outbound]) (Required.)

Participants: [Client/patient name or proxy name and relationship if not the patient]; [Staff name, credentials] (Required.)

Verification: [two identifiers confirmed / authenticated portal account / documented proxy relationship / unable to verify]

Outcome: [contact confirmed / message left / unread portal message / no answer] (Required. For voicemail or unread message, explicitly note contact was not confirmed.)

Reason for Communication

[Chief concern or question in 1–2 sentences] (Use client's words when clarity matters. Include relevant context such as recent visit, pending result, or medication issue.)

Communication Summary

[Client-reported information] (Clearly attribute as client-reported; include symptoms with timing and severity, questions asked, and home measurements if provided.)

[Clinician review] (If chart data, results, or medications were reviewed to respond, note what was reviewed and pertinent findings.)

[Information provided to client] (Summarize key points conveyed. For voicemail or unread messages, document only what was left and do not claim client understanding.)

Assessment & Plan

[Clinical impression] (Include only if clinical reasoning occurred; omit entire section for purely administrative communications.)

• Disposition: [emergent / urgent / routine / home care] (State rationale and red flags assessed.)
• Advice: [Self-care guidance and return precautions—when to call back, seek urgent care, or go to ED]
• Medications: [Medication name] [old dose] → [new dose]; [rationale]; [monitoring discussed] (Only if changes made.)
• Orders/Referrals: [Orders placed, referrals made, or appointments scheduled] (Only if applicable.)
• Results: [Test name] ([date]): [result]; [interpretation] (Only if results communicated.)

Follow-Up

• Next steps: [Action item] — [client / clinic responsible] — [timeframe]
• Contingencies: [Instructions if symptoms worsen, result not received, or pharmacy issues]
• If no contact: [Attempt details; re-contact plan and timeframe] (Do not document client understanding.)

(Required: Date/Time, Mode, Participants, Outcome. Omit inapplicable items rather than marking N/A. Never document client understanding unless explicitly confirmed.)