Waitlist Status Change Documentation Note

Date of Note: [Date and local time of documentation]

Patient: [Full name and identifiers per policy]

Author Name/Role: [Name, credentials, and role]

Late Entry: [Yes / No] — [Current date/time], documenting event from [original event date/time]. (Only include if this is a late entry.)

Status Change Summary

Prior Status: [Prior waitlist/eligibility status]

New Status: [New waitlist/eligibility status]

Effective Date/Time: [Timestamp when status changed in the system] (Do not use note creation time.)

Reason: [Specific, behavior-based, neutral explanation] (Use objective, nonjudgmental language.)

Impact: [One sentence in plain language describing operational effect for the patient]

Communication

(Document all contact attempts. Do not state that the patient was informed unless contact actually succeeded.)

Contact Attempts:

• [Date/time] — [phone / portal / letter / in-person] — [outcome: reached patient, reached representative, voicemail left, no answer, letter sent] — [Interpreter: language / none]
• (Add line for each attempt.)

Message Delivery Status: [delivered / not delivered]

Discussion Summary (Include only if contact succeeded.)

What was explained: [Status change, reason, steps required to regain/maintain active status, deadlines, how to get help]

Patient/Representative questions: [Questions asked and responses provided]

Understanding verification: [teach-back / verbal confirmation / not confirmed]

• If confirmed: [Patient/representative paraphrase or restatement of key requirements]
• If not confirmed: [Reason, e.g., patient not reached, declined discussion]

Action Plan

Patient tasks:

• [Task] — [Where/how] — [Deadline] — [Contact info for assistance if needed]
• (Add lines as needed. Use "Pending—[owner] to clarify by [timeframe]" if detail is unknown.)

Program/Team tasks:

• [Action] — Owner: [name/role] — Due: [date/timeframe]
• External notifications (if required): [Date] — [Recipient] — [Method]

Next review:

Reassessment trigger: [Upon receipt of required items / at next selection meeting / specific date]

Escalation if no response: [Follow-up call date, second attempt, certified letter per policy]

(Omit sections that do not apply rather than leaving empty placeholders.)