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Monthly HIV Check‑In · Case Note Generator

Monthly HIV Check‑In — Case Note Generator

One page. Ask the essentials. Get a clean note in simple, respectful language. No data leaves this page

Use on a private, trusted device only. Avoid entering full names or sensitive details on public computers.

Client Check‑In Form

EncounterBasics

Client (first name or initials)

Case Manager

Date

Start

End

Method

Language

Identity verified & consent confirmed Interpreter needed

1General Well‑Being

How have you been feeling this month?

Any new health issues or symptoms?

ER/urgent care/hospital since last check‑in

If yes, what happened?

2HIV Care & Medication

Taking HIV meds daily?

Missed doses this month

What helps you take them?

Barriers this month (select all)

Forgot Work/schedule Side effects Ran out Cost/coverage Stigma/privacy Other

Side effects or medication challenges

LabsHIV VL & CD4 only

Latest Viral Load

VL Date

Latest CD4

CD4 Date

3Appointments & Logistics

Upcoming appointments/labs

Help needed (select all)

Scheduling Reminders Transportation

4Access & Support

Coverage

Issues getting meds (refill, pharmacy, coverage)

Immediate needs (select all)

Food Housing Utilities Transportation Legal/ID Employment

5Mental Health & Safety

Mood this month

Stressors (select all)

Money Family Work Health Housing

Safety

Feels safe at home Feels safe in relationships

Interested in counseling/peer support

Anything else to share

6Referrals & Plan

Referrals offered (select all)

Benefits Specialist Housing Specialist Career Specialist Mental Health Peer Support

Warm handoff completed

Plan/notes

7Follow‑Up

Next check‑in date

Preferred time window

Case Note (Preview)

Quality checks

Adherence summary pending…
Safety check pending…
Follow‑up date pending…

Tips for simple, respectful language

Use short sentences, present tense, and everyday words.
State facts without judgment. Note barriers and supports.
Include only VL/CD4 for labs unless more detail is needed.

Built for monthly HIV check‑ins · Keep client dignity at the center · ©

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