Principal Illness Navigation Monthly Note (PIN)

Service Period: [MM/DD/YYYY – MM/DD/YYYY]

Navigator: [name, credentials]

Supervising Practitioner: [name, if applicable]

Principal Illness: [condition with severity/risk markers]

Initiating Visit: [date and treating practitioner]

Consent Status: [on file / obtained this month / needs verification]

(Document within navigator scope: observations, patient-reported information, chart-derived facts, and coordination activities. Do not document diagnoses, medication changes, or clinical interpretations; instead record notifications sent to treating clinicians. Attribute sources as patient-reported, caregiver-reported, observed, or chart-derived.)

Monthly Summary

[Brief narrative of interval events, navigation focus areas, and overall trajectory] (3–6 sentences. Include hospitalizations, ED visits, treatment changes, or missed appointments if relevant. Conclude with engagement/access status: [improving / stable / declining].)

Assessment

Barriers: [Active barriers with attribution] (Describe access/logistics, financial, health literacy, SDOH, or psychosocial barriers as applicable. Specify source for each: [patient-reported / caregiver-reported / observed / chart-derived]. Use person-first language. If no material changes: "Barriers reviewed; no changes; continuing [active workstreams].")

Patient Goals: [Patient-stated goals and preferences] (Include direct quotes when helpful. Translate into measurable navigation goals when possible. If unchanged and previously documented, note briefly.)

Navigation Activities

(Document interventions and coordination performed this month. Combine related activities. For care coordination, include date, recipient/role, modality, purpose, and outcome. Document closed-loop follow-up for clinician notifications and referrals. If safety concerns or escalations occurred, document the concern, who was notified, and disposition. Omit this section only if no navigation activities occurred—document inability to reach patient under Progress & Plan instead.)

• [Barrier or goal addressed]: [Actions taken] → [Outcome/status] → Next: [owner and next step]
• [Care coordination]: [Date, recipient, modality, purpose, outcome]
• (Add workstreams as needed.)

Progress & Plan

Goal Status: [met / partially met / not met / deferred] (Provide brief supporting evidence or objective measures when available.)

Next Month: [Planned navigation steps, pending appointments/milestones, patient/caregiver commitments, follow-up timeframe, and criteria for earlier contact if applicable] (If patient not reached this month, summarize outreach attempts and plan for next contact window.)

Activity Log

(Omit this entire section if not billing or tracking time. Do not include partial or estimated time if billing is intended.)

[Date | Minutes | Activity/Modality | Outcome]

(Add line items as needed.)

Monthly Total: [X] minutes

Attestation: Services provided under direction of [supervising practitioner] in accordance with established treatment plan for [principal illness].

Navigator Signature: [name/credentials]

Practitioner Verification: [signature, if required by billing policy]