Choose a structure that fits the work
A template should prompt useful detail without deciding the participant’s story in advance. Start with the service you delivered and your organisation’s record requirements. Leave out headings that encourage staff to make clinical judgements outside their role.
Three common formats
- SOAP: subjective information, objective observations, assessment and plan. Attribute reported information and stay within your professional scope.
- BIRP: behaviour or presenting concern, intervention, response and plan. Describe what happened rather than labelling the person.
- DAP: data, assessment and plan. Keep the evidence visible behind the interpretation.
For a routine coordination contact, a plain sequence of purpose, action, participant response and next step may be more useful. A longer form is not automatically a better record.
Copy this starting structure
Purpose of contact: What needed attention today?
Actions: What did you do, and who was involved?
Participant response: What did the participant report, choose or agree?
Follow-up: Who will do what next, and when?
Service details: Date, method, actual duration and relevant evidence.
Make the example your own
Never leave sample names, invented outcomes or pre-filled “no concerns” statements in a saved record. Check every field and attachment. If you use AI to prepare a draft, review it against the source information before saving.
The CordoCare template library gives you the available starting points. Read a worked note example, then test the same task on your phone in the product tour.