General · Templates

Care coordination note template

Built for the work between visits: document what you’re coordinating, who’s involved, barriers, and who owns the next action—so case management and clinician outreach don’t live only in inboxes.

Template content

Copy or download, then paste into Wavo under My Templates.

Care Coordination Note

Coordination Context
- Date/time, documenting role (RN, care manager, clinician, social work), and trigger (discharge, referral lag, abnormal result, patient request, risk flag).

Patient Goals
- What the patient/caregiver wants from coordination right now.

Clinical Situation (Brief)
- Relevant diagnoses, recent utilization (ED/hospital), and the care gap being addressed.

Contacts & Stakeholders
- Patient/caregiver, PCP, specialists, home health, pharmacy, payor, community resources—who was contacted and outcome of each attempt.

Barriers
- Transportation, cost, literacy/language, housing, food, insurance authorization, cognitive/behavioral barriers, and caregiver limits as discussed.

Actions Taken Today
- Appointments scheduled, records sent, authorizations started, education provided, safety check-ins completed.

Open Tasks & Owners
- Numbered next actions with responsible person and due date.
- Escalation path if tasks stall.

Follow-Up
- Next coordination touchpoint and criteria for clinician escalation.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Makes ownership of next actions explicit across roles.
  • Surfaces SDOH barriers that block the clinical plan.
  • Works for RN care managers, navigators, and clinician coordination time.
  • Leaves a trail other team members can pick up without a phone tag novel.
  • 1RN and care-manager outreach documentation
  • 2Post-discharge and high-risk patient coordination
  • 3Multidisciplinary care conference follow-ups

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Context
RN care manager outreach 7/26/2026 after hospital discharge 7/22 for CHF exacerbation; trigger: no PCP follow-up on calendar.

Goals
Patient wants to avoid readmission; daughter requests help with diuretic schedule and transportation.

Situation
HFrEF, new furosemide increase; BMP pending; home scale obtained. Missed prior PCP slot due to no ride.

Contacts
Reached daughter (preferred contact). PCP office scheduled visit 7/28 10:00 with transport via county van booked. Pharmacy confirmed spironolactone filled. Home health RN start pending auth—submitted today.

Barriers
Transportation; fixed income; limited health literacy for weight log—taught using fridge magnet log.

Open Tasks
1) CM to confirm home health auth by 7/29 (CM). 2) Patient bring weight log to PCP (patient/daughter). 3) Clinician review BMP when resulted (PCP).

Follow-Up
CM call 7/29; escalate to PCP same day if weight +3 lb or dyspnea at rest.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.