Step 1 · Practice setting Which kind of work are you documenting?
Clinical services Clinical notes, treatment plans, and optional diagnostic reference support Community health / case management Non-clinical notes, navigation plans, and local resource coordination
Professional role
Clinician Social Worker Therapist Counselor Case Manager Care Coordinator Community Health Worker Provider
How should the person be described?
Client Patient Member Individual Participant Person Served
Step 3 · Guided information
Add the facts you want the document to use.
You can paste a summary, answer the guided questions, or use both. Skip anything that does not apply. Do not include direct identifiers.
Source notes or overall summary Paste de-identified notes in your own words and order.
Purpose and context Why did the contact occur? Include setting, participants, modality, or duration only if documented. What the person reported Concerns, symptoms, priorities, changes, and impact on daily functioning, in the person's account. What you observed or verified Direct observations, records checked, or information confirmed by another source. Name the source, not the person. Services or interventions and response What was actually completed, what was only discussed or planned, and how the person responded. Goal progress and next steps Connection to an existing goal, progress or lack of progress, responsibilities, follow-up, and timing if known.
Planning details
Strengths, priorities, and preferences Include language, cultural, accessibility, and practical preferences when relevant. Baseline and measurable outcome Current starting point, desired change, indicator, target, and timeframe, only if known. Planned services and responsibilities Actions, responsible person or role, frequency, and duration. Separate agreed actions from proposals. Barriers, review, and transition Likely barriers, accommodations, coordination needs, review point, and completion or transition criteria.
Diagnostic reference details
Diagnostic context Timeline, severity, functional impairment, relevant history, medical or substance context, and prior diagnostic information. Safety assessment completed Document only questions actually asked and findings actually obtained. Do not infer absence of risk.
Local resource matching
Resource or referral needs Examples: food, rent, transportation, benefits, primary care, legal aid, or employment. The search uses broad need categories, not the progress-note narrative itself.