Patient Communication Note (Portal Message, Phone, or Text)

Date/Time: [date and time of communication] (Include duration for phone calls if relevant.)

Modality: [Portal Message / Phone / Text]

Participants: [patient and/or caregiver/guardian; include relationship if not the patient]

Author: [name and role]

Reason for Contact

[Primary question or concern(s) summarized concisely; include a brief patient quote only if it clarifies the issue] (Use 1–2 sentences. If multiple concerns exist, list them succinctly. Summarize—do not copy long message threads verbatim.)

Pertinent History / Data Reviewed

(Include this section only if additional clinical context is needed; otherwise omit entirely.)

[Relevant symptoms with timing and severity; pertinent medications; home measurements if provided; chart data reviewed that informs this decision] (Note any missing information that limits the assessment.)

Assessment

[Clinical impression or working diagnosis with level of certainty; key positives and negatives supporting the disposition] (Use 1–2 sentences. If multiple problems are addressed, organize by clinical priority. Limited inference from history and chart review is acceptable when clearly labeled. Do not assume resolution, adherence, or understanding unless explicitly confirmed.)

Plan

(Be specific. Include doses, frequencies, durations when applicable.)

• [Specific advice, self-care instructions, and monitoring parameters]
• [Medication changes: drug name, dose, frequency, duration; note if prescription sent] (Include only if medications were started, stopped, or changed.)
• [Orders placed and brief rationale] (Include only if orders were placed.)
• [Follow-up plan: timing and method]
• [Patient confirmed understanding of key instructions] (Include for high-stakes advice; note if patient declined recommendation with risk counseling provided.)

Return Precautions: [Specific red-flag symptoms prompting urgent evaluation; where and when to seek care] (Include whenever symptoms, medication changes, or clinical uncertainty are present. Omit only if purely administrative communication.)