SUD Case Management/Care Coordination Note

Date of Service: [date] Time: [start–stop or total minutes] Author: [name, role/credentials, organization] Patient: [name, MRN] Modality: [in-person / phone / video / secure message / community outreach / collateral-only] Location: [clinic / community setting / hospital or ED / shelter / other] Participants: [patient; family/support persons; interpreter; peer; probation; other providers as applicable]

(This note documents SUD-focused case management and care coordination activities. Exclude psychotherapy process content; summarize coordination-relevant facts only. Use person-first, non-stigmatizing language and attribute sources: patient-reported, collateral-reported, chart-verified, or observed. If late entry, state "Late entry" with brief reason at start.)

Reason for Contact

[Trigger and purpose of coordination activity in 1–3 sentences] (Include trigger type: follow-up from prior plan, patient request, provider referral, post-discharge outreach, benefits/housing crisis, MOUD coordination need, etc. Link to care plan goal if applicable. Include patient's stated priority if known.)

Consent / Information-Sharing Status

ROI status: [Active ROI on file for (recipients/purposes) / No ROI on file / ROI expired / Patient declined]

Disclosures this encounter: [No external disclosures made / Contacted (name/agency) regarding (category of information) per ROI on file] (If consent sought but declined or patient unreachable, document that.)

Actions & Outcomes

[Coordination activities performed with outcomes] (Use concise bullets organized by problem domain—treatment access, MOUD/OTP coordination, medical/psychiatric linkage, benefits/insurance, housing, employment, legal, transportation, peer supports—or as chronological contact log if multiple brief contacts. For each action: what was done, who was contacted, outcome achieved or pending, and patient response. Include risk/safety concerns and immediate actions only when clinically indicated. Note barriers only when they explain deviation from standard next steps. Omit domains that did not apply.)

Plan

(Prioritized next steps with task owner and timeframe. Include contingency if primary plan may fail. For high-risk situations, include safety follow-up timing.)

• [Task]: [Owner] by [date/timeframe]
• [Task]: [Owner] by [date/timeframe]
• [Contingency if needed]: [Owner] by [date/timeframe]

[Forms completed, applications submitted, or care plan updated] (Include only if applicable.)

Signature

Signature: [electronic signature with credentials, date/time]
Co-signature: [name, credentials, date/time] (Include only if required by policy.)

(Omit sections that do not apply except Consent status and Signature. For missing information use: "Not assessed this contact," "Patient declined," "Unable to obtain—[attempts made]," or "Pending—[what is needed]." Document stated intent and verified facts only; do not infer patient actions.)