Student Telephone/Portal Encounter Note

Date/Time Received: [Date and time received]

Date/Time of Contact: [Date and time of direct contact / Portal only—no direct contact]

Modality: [Telephone / Portal message / Voicemail]

Patient Location: [City, State / Not obtained—reason]

Callback Number: [Number / Not obtained—reason / Not applicable—portal only] (Omit for portal-only if escalation not anticipated.)

Student: [Name, role/level, service]

Identity Verification: [Two identifiers used, e.g., name and DOB]

Caller/Sender: [Patient / Proxy—name, relationship, and authority to discuss care]

Interpreter Used: [Yes—interpreter ID / No]

Reason for Contact & Triage Screen

Chief Concern: [Chief concern in patient/caller words, with context and onset/timeline if applicable]

Pertinent History: [Brief symptom descriptors, relevant PMH, pertinent medications/allergies, home-reported data reviewed, prior self-care and response; note chart review findings with source if performed; document discrepancies between patient report and chart] (Include only details that inform triage decision. If safety-relevant information not obtained, state reason.)

Safety Screen:

• Red flags denied: [Relevant negatives for this complaint]
• Red flags present: [Positives with details—onset, severity, associated features / None]
• Screen status: [Complete / Incomplete—reason]

Assessment & Plan

Working Impression: [Symptom- or problem-oriented impression with acuity framing] (Avoid definitive diagnoses unsupported remotely. If supervisor input informed assessment, state "Per supervisor [Name/Role]".)

Advice Given: [Self-care recommendations; medication guidance with dose/frequency; expected course; when to call back] (Note source: per student / per protocol / per supervisor.)

Disposition: [Home care / Same-day clinic / Urgent care / ED now / Call 911 / Routed to RN or MD—specify] [Timeframe]

Return Precautions:

• [Symptoms or changes prompting immediate ED/911]
• [Symptoms or changes prompting callback to clinic]

Understanding Confirmed: [Teach-back performed—Yes/No; understanding verbalized—Yes/No; barriers noted / Not assessed—reason]

Orders/Prescriptions/Referrals: [Items with who placed each] (If verbal orders, document read-back confirmation.) (Omit section if none.)

Supervision & Follow-up

Supervisor Notification: [Yes / No] (If Yes: who, when, method, what communicated, supervisor response/plan, and whether supervisor spoke directly with patient.)

Routing/Follow-up: [Messages routed; planned callbacks with owner/timeframe; unsuccessful contact attempts with date/time/method] (Omit if none.)

Student Signature: [Name, role, timestamp]

Supervisor Co-signature: [Name, role, timestamp] (As required by policy.)