Community Health Worker Encounter Documentation

A documentation form for community health workers to record patient encounters, social needs screening, outreach activities, referrals, and follow-up actions for continuity of care and reporting.

Encounter Details

• Encounter Date
  Date the encounter occurred.
• Encounter Time
  Optional time of the encounter.
• Encounter Type
  Select the primary mode of contact.
• Encounter Location
  Where the encounter took place, if relevant.
• Patient Identifier
  Enter the local patient ID or other internal identifier. Avoid collecting SSN or other unnecessary PII.
• Consent to Document Encounter
  Confirm that the patient was informed about documentation and any applicable sharing for care coordination and reporting.

Reason for Encounter

• Primary Reason for Encounter
  Choose the main reason for the encounter.
• Referral Source
  How the patient was connected to CHW services.
• Presenting Concerns
  Briefly summarize the issues discussed. Include only information needed for follow-up.
• Any urgent safety concern identified?
  Indicate whether an immediate safety issue was identified.
• Urgent Safety Concern Details
  Describe the concern and any immediate escalation or handoff completed.

Social Needs Screening

• Social Needs Identified
  Select all needs discussed or identified during the encounter.
• Food Insecurity Details
  Document relevant details, barriers, and household context as needed.
• Housing Instability Details
  Document housing-related barriers or risks using minimum necessary detail.
• Transportation Barriers Details
  Describe transportation barriers affecting access to care or services.
• Other Needs Details
  Describe any additional social needs not listed above.

Interventions and Referrals

• Interventions Provided
  Select all actions completed during the encounter.
• Referrals Made
  Add one row for each referral or resource connection.
• Referral Type Options
• Patient Accepted Referral or Resource?
  Indicate whether the patient accepted the referral or resource.
• Barriers to Follow-Through
  Document barriers that may affect completion of the referral or next steps.

Follow-up and Next Steps

• Follow-up Needed?
  Indicate whether additional follow-up is needed.
• Planned Follow-up Date
  When the next contact should occur.
• Next Steps
  Summarize the plan, responsibilities, and any handoff completed.
• Escalation or Handoff Completed?
  Indicate whether the issue was escalated to a supervisor, clinician, or partner organization.
• Escalation Details
  Document who was contacted and what information was shared using minimum necessary detail.

CHW Notes and Certification

• Additional Notes
  Include any other relevant details not captured above.
• CHW Name
  Name of the community health worker completing the form.
• CHW Signature
  Signature confirming the encounter documentation is accurate.
• Attestation
  I certify that this documentation is accurate and completed in accordance with organizational policy and applicable privacy requirements.