Telephone/Portal Encounter Note (Care Coordination)

Date/Time: [Encounter date and start time; end time if applicable]

Encounter Type: [telephone - incoming / telephone - outgoing / patient portal message - incoming / patient portal message - outgoing / other asynchronous]

Participants: [Patient present / caregiver-only]; [Caregiver name, relationship, authority if applicable]; [Clinician name, credentials, role]; [Interpreter language if used]

Identity Verified: [Method of verification / authenticated portal account]

Unsuccessful Contact Attempt

[Attempt number] | [Date/Time] | [Method] | [Outcome: no answer / voicemail left / message undeliverable]

[Voicemail left without detailed PHI if applicable]

[Next steps and planned re-attempt timeframe; responsible party]

(Use this section in place of the sections below when contact was not completed; omit the remaining sections.)

Reason for Contact

[Chief concern or clinical question in 1–3 lines; use patient's words when helpful]

[Urgency category if relevant]

Clinical Information

[Pertinent context and subjective information obtained, including onset, duration, severity, trajectory, and pertinent positives/negatives for symptoms] (Include only details that materially affect clinical reasoning. Do not include physical examination findings.)

Home measurements: [Values, source/device, date/time] (Include only if provided.)

Data reviewed: [Recent labs, imaging, visit notes, or other records reviewed and pertinent findings] (Include only items that influenced reasoning.)

Assessment & Plan

Assessment: [Working assessment or clinical impression for each problem addressed]

Recommendations: [Self-care guidance, monitoring parameters, dose adjustments, and other advice provided]

Orders: [Orders placed] (State "no orders placed" if none.)

Follow-up: [Timeframe and modality]

Contingency instructions: [Specific red flags that should prompt urgent evaluation and where to seek care] (Always include for symptom-related calls.)

Patient understanding: [Teach-back confirmed] (Include only if performed.)

Care Coordination

[Actions taken: appointments scheduled, referrals placed, prior authorizations initiated, records requested/sent, external communications completed] (For each action, note relevant details such as destination, method, outcome, and pending responses.)

Pending tasks: [Task description, responsible party, and timeframe] (Include only if tasks remain open.)

Medication Updates

[Medication starts, stops, or changes with name, dose, route, frequency, indication, and special instructions] (For refills without clinical change, state explicitly. Note if medication reconciliation was performed.)

(Omit this section if no medications were discussed.)

Author: [Name, credentials]

(Omit any sections that do not apply to this encounter.)