CHW Packet – Community Connections Daily Note

Client Name *

First

Last

Date of Service

Time In

Time Out

Location Of Service:

12 Home
04 Homeless Shelter
11 Office
53 Health Center

Home: Having a stable and safe place to live
Health: Overcoming or managing one's disease(s) or symptoms, and making informed, healthy choices that support physical and emotional well being
Purpose: conducting meaningful daily activities, such as a job, school, volunteerism, family caretaking or creative endeavors and the independence, income and resources to participate in society
Community: Having relationships and social networks that provide support, friendship, love and hope

ICD 10: Home

Z59.1 Inadequate Housing
Z59.9 Problems related to housing economic Circumstances Unspecific

ICD 10: Health

Purpose:

Z59.6 Low Income
Z55.9 Problems related to education
Other

Other:

Community:

Z63.0 Problems in relationship
Z63.5 Disruption of family Separation and Divorce
Z63.8 Other Problem related to Primary Support Group
Z65.3 Problems related to other Legal Circumstances
Other

Other

CHW Plan of care: Progress notes based on ICD 10

1. Home:

1. Plan for next session

2. Health:

2. Plan for next session

3. Community - Relationships:

3. Plan for next session

4. Purpose:

4. Plan for next session

Notes that need coordination with Primary Clinician:

Signature of CHW:

Clear Signature

*The signing of this note declares this information to be accurate and a true representation of services provided

Date

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FC Email: