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Run: Community Health Worker Encounter Documentation

Document patient encounters, social needs, referrals, and follow-up actions in one CHW encounter form. Use it to keep continuity of care clear, capture conse...

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Encounter Details

Encounter Date (required)

Date the encounter occurred.

Encounter Time

Optional time of the encounter.

Encounter Type (required)

Select the primary mode of contact.

Encounter Location

Where the encounter took place, if relevant.

Patient Identifier (required)

Enter the local patient ID or other internal identifier. Avoid collecting SSN or other unnecessary PII.

Consent to Document Encounter (required)

Confirm that the patient was informed about documentation and any applicable sharing for care coordination and reporting.

Yes No N/A

Reason for Encounter

Primary Reason for Encounter (required)

Choose the main reason for the encounter.

Referral Source

How the patient was connected to CHW services.

Presenting Concerns (required)

Briefly summarize the issues discussed. Include only information needed for follow-up.

Any urgent safety concern identified? (required)

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 (required)

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? (required)

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? (required)

Indicate whether additional follow-up is needed.

Planned Follow-up Date

When the next contact should occur.

Next Steps (required)

Summarize the plan, responsibilities, and any handoff completed.

Escalation or Handoff Completed? (required)

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 (required)

Name of the community health worker completing the form.

CHW Signature (required)

Signature confirming the encounter documentation is accurate.

Attestation (required)

I certify that this documentation is accurate and completed in accordance with organizational policy and applicable privacy requirements.

Yes No N/A

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