SMORES HEALTH. COMMUNITY HEALTH WORKER ENCOUNTER NOTE TEMPLATE
Reviewed October 9, 2026

Original general template, not a state-approved or payer-approved form. Review fields, access, signatures, corrections, and source requirements before operational use. This template does not determine reimbursement. Use fictional information during evaluation.

Approved participant record reference:
Program/service:
Worker:
Service date:
Entry date if different:
Setting and contact method:
Start/end time and relevant duration, if required:
Individual/group and required group details, if applicable:

PURPOSE
Participant priority and reason for this encounter:
Relevant service plan or approved education plan reference:
Applicable order/reference, if required:

ACTION
What the worker actually did:
Approved material/curriculum used, if applicable:
Relevant facts observed:
Information reported by the participant or another source (identify source):

RESPONSE
What the participant said, demonstrated, chose, or declined:
Questions or barriers still unresolved:
Referral stage and evidence (sent, acknowledged, scheduled, confirmed, unknown):

NEXT STEP
Agreed action:
Responsible worker/role:
Due date or agreed follow-up:
Contact preference and relevant sharing instructions:
Escalation under approved procedure, if applicable:

REVIEW
Author and completion status:
Required signature/review:
Program-specific fields added after source review:

QUALITY CHECK
[ ] Correct record, date, and worker.
[ ] Facts distinguished from reports and assumptions.
[ ] No unsupported diagnosis, outcome, or payment claim.
[ ] Attempts distinguished from completed encounters.
[ ] Next action has an owner and timing.
[ ] Unnecessary personal history omitted.
[ ] Corrections follow approved process, preserving relevant history.

Guide: https://smoreshealth.com/peer-support-software/community-health-worker-documentation-template
Demo: https://cal.com/team/smoreshealth/demo