Wellness Coordinator Encounter Note (SOAP)

Date/Time: [date and time of encounter]

Modality: [in-person / phone / video]

Participants: [patient; caregiver; interpreter with ID; other staff as applicable]

Reason for Encounter: [wellness coaching follow-up / initial wellness intake / goal check-in / other stated reason]

Subjective

[Patient priorities and agenda for today's encounter] (Summarize in 2–4 sentences using the patient's own framing. Include a direct quote if it captures a meaningful goal or motivation.)

Interval Progress: [changes since last visit—successes, setbacks, learning] (Omit for initial encounters.)

Patient Motivations: [why the goals matter; desired outcomes; personal values]

Barriers: [patient-identified obstacles] (Do not infer barriers without explicit patient report.)

Facilitators: [strengths, supports, resources, prior successes]

Readiness/Confidence: [confidence ruler 0–10 with brief context]

Social Needs: [reported need and whether assistance is desired] (Include only if screening administered or patient reports a social need affecting goals.)

Safety Concerns: [red-flag symptoms or safety issues; immediate action taken] (Include only if reported.)

Objective

(Include only data available and relevant to this encounter. Attribute sources: measured today, patient-reported, or chart review with date. Omit items not assessed.)

Vitals/Measurements: [measurement, value, source] (Omit if none taken.)

Clinical Data Reviewed: [relevant labs or chart items with dates] (Include only if reviewed for this encounter.)

Screening Tools: [tool name; score; brief interpretation] (Include only if administered or reviewed today.)

Encounter Observations: [objective observations of engagement or affect] (Avoid diagnostic labels.)

Assessment

[Wellness-focused synthesis] (3–5 sentences: patient's primary focus areas, key barriers and strengths, readiness/confidence level, and what was agreed upon. If clinical escalation occurred, note the concern and that the clinical team was notified.)

• [Focus area]: [one-line status—current state and readiness]
• [Additional focus areas as applicable]: [one-line status]

Plan

[Patient-chosen focus summary] (Begin with one sentence emphasizing patient ownership, e.g., "Patient chose to focus on…")

SMART Goals: (For each focus area, document at least one goal.)

• [Focus area]: [specific behavior and frequency] | Measure: [how tracked] | By: [timeframe] | Barrier plan: [if applicable] | Confidence: [0–10]
• [Additional focus area]: [specific behavior and frequency] | Measure: [how tracked] | By: [timeframe] | Barrier plan: [if applicable] | Confidence: [0–10]

Education Provided: [topics; method—discussion/handout/demonstration; patient understanding or teach-back response]

Referrals/Resources: [service or program; reason; how placed; patient acceptance] (Omit if none.)

Team Communication: [who notified; what communicated] (Include only if escalation or coordination occurred.)

Follow-up: [timing; modality; focus for next encounter]

Safety Instructions: [return precautions or symptoms to watch for] (Include only if relevant.)

Signature

Documented by: [name, credentials, role/team]

Date/Time Signed: [date and time]

(General instructions: Omit fields not addressed rather than inserting "N/A." Distinguish clearly between patient-reported, measured, and chart-reviewed data. Use neutral, non-stigmatizing language throughout.)