Recovery Coach Documentation: Notes That Protect

Disclaimer: Educational content only. Not legal or medical advice.

Why Notes Matter

Notes make your work transparent, reduce confusion, support clean handoffs, and help you see patterns. They’re also your best defense against scope creep.

What to Capture Every Session

• Date, start/end time, and format (in person, phone, video)

• Client goal for today in their words

• Actions taken: skills practiced, plans made, referrals

• Risk check: sleep, mood, cravings, safety, housing, food, withdrawal symptoms

• Follow‑ups: who does what by when

• Consent updates: new/changed releases or expirations

What to Avoid

• Diagnoses, treatment advice, or medication dosing guidance

• Interpreting labs or other clinical data

• Moral judgments or speculation

Note Template and Coordination Log PDFs coming soon...

Tip: Keep it under 8–10 lines. If it’s getting long, you’re probably drifting into clinical territory or storytelling.

Storage & Privacy Basics

• Use a secure app or encrypted drive

• Limit access strictly on a need‑to‑know basis

• Back up weekly (encrypted)

• Set a retention policy that fits your setting and state rules

• Keep a current list of active consents with end dates

Red Flags to Document Plainly

• Expressed intent to self‑harm or harm others

• Acute medical symptoms

• Loss of housing or personal safety concerns

• Loss of access to medications or essential supports

Keep it factual and action‑oriented: what was said, what you did, who you contacted (with consent or due to safety), and next steps.

Quality Check Before You Save

• Facts only, client‑focused, clear next steps

• No clinical language or diagnosis

• You’d be comfortable reading it aloud to the client

• Timestamped and signed/initialed