Community Health Integration Monthly Note (CHI)

Note Type: Community Health Integration Monthly Note

Reporting Period: [start date] to [end date]

Patient: [per system standard]

CHI Staff: [name, role/credentials]

Supervising Practitioner: [name, role/credentials] (Include only if required by workflow.)

Contact Modes: [modes used during this reporting period]

Consent/Prerequisites: [consent status; initiating visit date] (Include only if CHI billing applies; otherwise omit.)

Monthly Summary

[4–6 sentence narrative covering: top 1–3 prioritized social needs; key navigation/coaching actions performed; referral activity and linkage outcomes (connected vs pending vs unsuccessful); any safety concerns or escalations; primary focus for next month.] (Use plain, person-first language. Avoid acronyms unless defined.)

Social Needs & Goals

Assessment: [tool used, date, source] (Specify whether patient self-report, collateral, or record review. If not assessed this period, state reason.)

[Social need category]: [patient-stated need and impact on health care/treatment] | Priorities: [patient preferences] | Barriers: [relevant barriers] | Status: [improved / worsened / unchanged / new / resolved] | Goal: [patient-stated goal, use direct quote if meaningful]

(Repeat for each active social need. If none active, provide one-line attestation: "No unmet social needs identified this period" or "Not assessed due to [reason].")

Activities & Referrals

(Organize by social need addressed. Document only activities performed during this reporting period.)

[Social need category]:

• Interventions: [education, coaching, navigation, application support, advocacy, accompaniment, etc.]
• Coordination: [clinic team and community partners engaged; key coordination steps]
• Patient response: [engaged / partially engaged / not reached / declined] — [brief narrative]
• Outcome: [result of actions this period]

(Repeat for each social need addressed.)

Referrals:

• [Date] | [Need addressed] | [Organization/Program] | Status: [Submitted / Scheduled / Connected / Completed / Denied / Patient Declined / Waitlisted] | Source: [patient report / agency confirmation] | Follow-up: [next step with target date] | Barriers/Remediation: [if applicable]

(Repeat for each referral. If no referrals made, state: "No community referrals made this period.")

Plan

• [Open items and pending referrals with target dates]
• [Planned follow-up cadence and mode]
• [Escalation triggers] (Include only if applicable.)

Time Summary

(Include only when workflow requires time accounting or billing documentation.)

Total Minutes This Period: [numeric minutes]

• [Date — minutes — activity — staff] (Repeat per activity. Use explicit numeric minutes.)

[Attestation statement] (Include only if mandated by workflow.)

Author: [name, credentials]

Date/Time Signed: [date and time]

Supervising Practitioner Review: [review statement, name, credentials, date/time] (Include only if required by workflow.)