How to Write Care Coordination Notes

Care Coordination Note Template You Can Copy and Adapt

A care coordination note documents clinically relevant communication, referrals, updates, and follow-up tasks related to a client’s care. Therapists often use this note after speaking with another provider, contacting a school, coordinating with a case manager, discussing medication concerns with a prescriber, or helping a client connect with a higher level of care.

The template below is designed for behavioral health documentation. Adjust the fields to match your practice setting, payer requirements, electronic health record, and clinical workflow.

Care Coordination Note

Client Name:
Client ID or DOB:
Date of Contact:
Time of Contact:
Type of Contact:
☐ Phone
☐ Secure message
☐ Email
☐ Fax
☐ In-person
☐ Care team meeting
☐ Other:

Person or Organization Contacted:
Name:
Role/Title:
Organization:
Contact Information:
Release of Information on File:
☐ Yes
☐ No
☐ Not required per practice policy / applicable exception
☐ Other:

Reason for Coordination:
Briefly state why coordination occurred. Include the clinical or care-related purpose.

Summary of Information Shared or Received:
Document relevant information only. Include updates related to symptoms, functioning, risk, medication, referrals, treatment plan needs, barriers to care, or service transitions.

Clinical Relevance:
Explain how the information relates to the client’s treatment goals, current needs, safety planning, continuity of care, or treatment plan.

Actions Taken:
Document what the clinician did during or after the contact.

Client Involvement or Consent:
Note whether the client requested, consented to, participated in, or was informed of the coordination, as applicable.

Plan and Follow-Up:
List next steps, responsible parties, and target dates when known.

Clinician Name and Credentials:
Signature:
Date Finalized:

Completed Care Coordination Note Example

This example shows how the template can be used after a therapist coordinates with a psychiatric prescriber. Details are fictional and should not be copied into a real client record.

Care Coordination Note

Client Name: Jordan M.
Client ID or DOB: 04/18/1992
Date of Contact: 08/14/2026
Time of Contact: 2:15 PM - 2:32 PM
Type of Contact: Phone

Person or Organization Contacted:
Name: Dr. R. Patel
Role/Title: Psychiatric Nurse Practitioner
Organization: Community Behavioral Health Associates
Contact Information: On file
Release of Information on File: Yes

Reason for Coordination:
Client reported increased anxiety, disrupted sleep, and difficulty completing work tasks during the past two weeks. Client requested that therapist coordinate with psychiatric prescriber before upcoming medication management appointment.

Summary of Information Shared or Received:
Therapist shared client-reported increase in generalized worry, sleep latency of approximately 90 minutes, and recent use of grounding skills during work-related anxiety. No current suicidal ideation, homicidal ideation, or psychotic symptoms reported in most recent therapy session on 08/12/2026. Dr. Patel reported client has a medication follow-up scheduled for 08/19/2026 and requested that client track sleep, caffeine use, and timing of anxiety symptoms before the appointment.

Clinical Relevance:
Coordination supports continuity between psychotherapy and medication management. Information is relevant to treatment plan goals of reducing anxiety symptoms, improving sleep routine, and increasing use of coping strategies during occupational stress.

Actions Taken:
Therapist provided clinically relevant symptom update with client consent. Therapist agreed to encourage client to track sleep and anxiety patterns before prescriber appointment. Therapist documented prescriber request and will review tracking plan with client during next therapy session.

Client Involvement or Consent:
Client requested coordination during session on 08/12/2026. Valid release of information is on file for Community Behavioral Health Associates.

Plan and Follow-Up:
Client will attend medication management appointment on 08/19/2026. Therapist will review symptom tracking with client at next scheduled therapy session on 08/21/2026. Therapist will coordinate again with prescriber if clinically indicated and authorized.

Clinician Name and Credentials: Avery Lee, LCSW
Signature: Avery Lee, LCSW
Date Finalized: 08/14/2026

When Therapists Use Care Coordination Notes

Care coordination notes are used when communication outside the therapy session affects the client’s care. They are different from a standard progress note because the focus is not the full therapy session. The focus is the coordination activity: who was contacted, why the contact happened, what information was exchanged, and what follow-up is needed.

Common examples include coordinating with a psychiatrist about medication concerns, sending a treatment update to a primary care provider, consulting with a school counselor, following up with a case manager, documenting referral outreach, or participating in a multidisciplinary care meeting.

A care coordination note may be appropriate when the coordination activity affects:

• Treatment planning: A provider shares information that changes goals, interventions, referrals, or frequency of care.
• Continuity of care: The client is moving between providers, programs, levels of care, or service settings.
• Risk or safety planning: Communication relates to safety concerns, crisis planning, hospitalization, discharge, or support systems.
• Referral follow-through: The clinician helps document barriers, outreach attempts, scheduled appointments, or next steps.

Not every brief administrative message needs a detailed clinical note. For example, rescheduling a session or confirming an appointment may be documented elsewhere in the record. If the communication includes clinical information, care decisions, client needs, or provider recommendations, a care coordination note gives the record a clear place for that information.

What to Include in a Care Coordination Note

A useful care coordination note answers four basic questions: who was involved, why the contact occurred, what was discussed, and what happens next. The note should be specific enough that another clinician can understand the care activity without reading between the lines.

Contact details

Start with the date, time, method of contact, and name of the person or organization contacted. Include the person’s role, such as primary care physician, psychiatric prescriber, school social worker, case manager, probation officer, family member, or intake coordinator.

Document whether a release of information is on file when one is needed by your practice process. If the client participated in the call or requested the coordination, include that detail. If your setting has a specific way to record authorization status, follow that format.

Reason for coordination

State the purpose in one or two sentences. A strong reason is direct and connected to care.

For example: “Client requested therapist coordinate with psychiatric prescriber due to increased panic symptoms and concern about medication side effects.”

A weaker version would be: “Called doctor about client.” That does not explain the clinical purpose, the care need, or why the contact belongs in the record.

Information shared or received

Document relevant information without including unnecessary detail. If you shared symptom updates, treatment progress, risk information, appointment status, referral needs, or recommendations, summarize those points clearly.

Use neutral clinical language. Instead of writing, “School said client is being difficult,” write, “School counselor reported client has left class early three times this week following peer conflict and has requested support from the counseling office.”

Plan and follow-up

The follow-up section is where many care coordination notes become useful later. Name the next step, who is responsible, and the expected timing when known. This helps prevent coordination tasks from staying in someone’s memory or getting buried in email.

Examples include: “Therapist will send updated treatment goal summary by 09/10/2026,” “Client will call referral provider before next session,” or “Case manager will confirm transportation options and update client by Friday.”

Care Coordination Notes Compared With Progress Notes

A progress note usually documents a clinical service with the client, such as an individual therapy session, group session, intake, assessment, or family therapy session. It often includes interventions, client response, progress toward treatment goals, risk assessment, and plan.

A care coordination note documents a care-related contact or activity that supports treatment but may not be a therapy session. The clinician may be communicating with another provider, sending referral information, participating in a team meeting, or documenting a service transition.

Some practices combine referral and coordination documentation. Others separate them. The best format is the one your clinical team can use consistently while still capturing the information needed for continuity of care.

Common Mistakes in Care Coordination Documentation

Care coordination notes do not need to be long. They do need to be clear. Most problems come from vague wording, missing follow-up, or including information that does not belong in the note.

• Writing “left voicemail” with no purpose: Include why you called and what follow-up is planned, especially if the outreach relates to referral, safety, discharge, or treatment planning.
• Leaving out consent or authorization status: If your workflow requires a release of information, document whether it is on file before noting what was shared.
• Documenting every detail from the conversation: Focus on clinically relevant information. A care coordination note is not a transcript.
• Missing the next step: A note that says “spoke with case manager” is less useful than a note that states who will do what by which date.

Another common issue is using emotionally loaded language. Care coordination often involves complex systems, frustrated clients, or conflicting reports. Keep the note objective. Attribute information to the source when needed, such as “parent reported,” “school counselor stated,” or “client denied.”

Documentation Tips for Clearer Care Coordination Notes

Clear care coordination notes are brief, organized, and connected to treatment. Before finalizing the note, read it as if another clinician will need it next month. Would they know what happened and what to do next?

Use a consistent order

A predictable structure helps you write faster and helps others scan the note. Start with the contact, then the reason, then the summary, then the plan. If your EHR has fields for care coordination, use them consistently.

Separate facts, reports, and clinical judgment

Care coordination notes often include information from several sources. Make the source clear. For example, write “Client reported difficulty sleeping,” “PCP reported recent lab work was completed,” or “Therapist assessed that coordination supports treatment goal related to anxiety management.”

Keep the note tied to the treatment plan

A short sentence can connect the coordination activity to care. For example: “This contact supports treatment plan goal of improving school attendance through increased communication between caregiver, school counselor, and therapist.”

Protect client privacy in routine workflows

Use the communication channels approved by your practice. Avoid placing sensitive details in unsecured messages, shared calendars, or informal task lists. If you are unsure how to document a specific disclosure, follow your organization’s policy and consult the appropriate supervisor, privacy officer, or legal resource.

Short Care Coordination Note Examples for Common Scenarios

Not every note needs the full template. A concise version may work for brief coordination tasks, as long as it captures the reason, relevant content, and plan.

Referral follow-up example

Therapist contacted Lakeside Eating Disorder Program intake line with client consent to confirm referral process and current availability. Intake coordinator reported estimated wait time of 2-3 weeks and requested referral form, diagnostic summary, and insurance information. Therapist informed client by secure message and will review referral documents with client during next session on 06/18/2026.

School coordination example

Therapist spoke with school counselor, Maria S., with caregiver authorization on file. School counselor reported client has visited counseling office twice this week due to anxiety before presentations. Therapist shared general coping strategies currently being practiced in therapy, including paced breathing and use of a coping card. School counselor will offer client access to counseling office before scheduled presentation on Friday. Therapist will process outcome with client at next session.

Discharge planning example

Therapist participated in discharge planning call with inpatient social worker and client. Inpatient social worker reported anticipated discharge date of 10/03/2026 and recommended outpatient therapy within seven days of discharge. Client requested to resume weekly sessions with therapist. Therapist scheduled follow-up appointment for 10/06/2026 and will review updated safety plan at that session.

These short examples work because they avoid unnecessary background and focus on care decisions. Each one names the contact, purpose, information exchanged, and next step.

How AutoNotes Helps Create Editable Care Coordination Drafts

Care coordination often happens between sessions, between client messages, or at the end of a packed clinical day. AutoNotes helps clinicians turn key details into structured, editable care coordination note drafts faster, while keeping the clinician responsible for review, edits, and final approval.

Instead of starting from a blank screen, a therapist can enter details such as the contact type, provider contacted, reason for coordination, information shared, and follow-up plan. AutoNotes can then generate a draft organized around a behavioral health documentation format. The clinician can revise wording, add clinical judgment, remove unnecessary detail, and finalize the note in the record.

For care coordination documentation, this can help with:

• Consistent structure: Drafts can follow a repeatable format for provider calls, referrals, school coordination, case management contact, and discharge planning.
• Faster first drafts: Clinicians can move from rough details to a usable note draft without building every sentence manually.
• Clearer follow-up tasks: Templates can prompt for next steps, responsible parties, and target dates.
• Clinician control: The provider reviews, edits, and finalizes the note based on the actual care activity and clinical judgment.

AutoNotes is built for behavioral health documentation, including progress notes, intake documentation, assessments, treatment planning, and care-related workflows. It is not a substitute for clinical judgment, supervision, payer guidance, or your practice’s documentation policies. It gives clinicians a more organized starting point.

Use a Clear Template Before the Details Fade

Care coordination notes are easiest to write soon after the contact occurs. Capture the basic facts first: who you contacted, why, what was shared, and what happens next. Then add the clinical relevance that connects the coordination activity to the client’s treatment plan, continuity of care, safety needs, or referral process.

If care coordination notes are taking too much time after sessions, AutoNotes can help create structured, editable drafts from your session and coordination details. You stay in control of the final note, with a faster path from care activity to completed documentation.

Start your free trial to see how AutoNotes can support faster, more consistent behavioral health documentation.