Record Keeping

Medical record keeping, in street medicine and other areas of medicine, serves the primary purpose of safeguarding continuity of care and patient safety. Other important purposes include patient care necessities, such as prescribing, referrals, and displaying lab or test results; legal and risk management; and billing. Medical records often allow clinicians to collect data for the purposes of quality assurance and document metrics for program evaluation and research. In each setting, medical records should be kept secure and private as required by law.

Street medicine medical record keeping differs from indoor medical settings in a variety of ways including demographic information, such as street names and lack of permanent address; location of encounters; and required forms, such as consent for treatment and acknowledgement of privacy policies. These aspects may influence record system choice, customization for the chosen system, or workarounds for programs that cannot select their own system.

Teams will likely use some mix of paper and electronic medical record (EMR) charting, and programs will need to determine the best method for integration. The Street Medicine Institute recommends against using only paper charts for programs that have sufficient funding or work within an organization that has an EMR. However, paper charting may be the only option for record keeping among low-resource programs.

While this guideline seeks to help street medicine programs consider various components of medical record keeping, each program has different needs and no one solution will be best for every team. The Street Medicine Institute does not endorse specific EMR systems, though some brand names are included as examples in this guideline.

Download the Record Keeping Guide PDF

Selecting an Electronic Medical Record System

Programs should use the EMR of their parent organization where applicable. Programs without access to an EMR may be able to select an EMR with customization for the street in mind, though cost may be significant for commonly used EMRs that offer systems-level integration with local hospitals or other cities. At the time of writing, there are no EMR systems specifically for street medicine. The right system will depend on the unique needs of the program, and no matter the system there should be a downtime/contingency plan in place. The following table compares possible available EMR systems.

Considerations When Adapting an EMR

Street medicine is a unique form of healthcare, so conventional record systems may need adjusting to be useful for outreach. The areas that often need changes can be loosely categorized into scheduling and visits, registration, care during outreach, and billing. These categories and their commonly encountered challenges and proposed solutions are covered in Appendix 1.

AI Note Writing Services

Some programs incorporate AI documentation services into note writing. While this can counter the burden of documentation, there is also risk for serious documentation errors. Ensure that patients are appropriately consented, and review all notes for accuracy before signing (Razaghi et al., 2026).

Integrating Electronic and Paper Charting

Most teams find that keeping field notes or paper records while on street rounds is simpler and allows encounters to feel more natural or conversation-like. Some clinicians, especially those driving to patient locations, elect to document in the EMR in the vehicle while another team member drives. Others may use their field notes as a reference to complete electronic charting upon return to the office. Some EMRs have speech to text capacity for charting which can make charting from field notes faster and easier, though this often requires a good cellular network connection.

Some teams prefer to complete a paper medical encounter form on street rounds and scan it into the medical record. Keep in mind, however, that scanning records will require additional time, and the scan may not be as quickly available or as accessible as electronic records. While writing might be faster for clinicians, these barriers plus writing legibility and scanning quality can impair easy communication and continuity of care.

See Appendix 2 for example medical encounter forms.

Street Medicine Charting

The following are unique elements and good practices relating to street medicine charting.

• Elements of street medicine charting:

• Homelessness history - examples include noting if someone is experiencing unsheltered homelessness or if they meet the definition of chronic homelessness, which can help patients qualify for specific housing or other benefits.
• Address/location - while someone who is unsheltered may not have a house address, they may use an address of a trusted friend or family member, post office box, or mail services through a homeless services agency for mail. Programs can also consider asking the patient “where will you move to if you need to relocate?”
• Contact information - consider asking for a phone number if they have one or the phone number of a friend.
• People experiencing homelessness may be estranged from family, so when asking about emergency contact or next of kin it can be helpful to ask about trusted friends or individuals they’ve identified as family.

• Additional helpful history elements are described in the HOUSED BEDS tool (Feldman et al., 2019).

• Set an example when charting and avoid stigmatizing language:

• Avoid words such as “disheveled”, “unkempt,” “drug abuser,” or “addict” as they do not contribute to medical information but stigmatize the patient. Use person-first language and refer to patients by how they want to be identified, whether by street name, gender identity, or something else (Vanka et al., 2025).
• Avoid charting “noncompliant” when a patient is unable to complete a plan and instead describe the reason and/or barriers. A patient’s ability to complete a care plan is heavily determined by external factors, and describing it as a personal failing is both incorrect and contributes to stigma (Beltrán et al., 2025). 

• When possible, choose specific diagnoses for chronic medical conditions and avoid “NOS” (not otherwise specified) diagnoses. This can help when medical documentation is later used for benefits and disability verification.

• People who are unsheltered are at higher risk of readmissions or increased use of the emergency department. It is helpful to document in detail so that clinicians in other services have a more accurate and comprehensive understanding of the challenges and therefore create an appropriate plan of care. It can also help to frame the experience to counter prevailing biases in traditional settings.

• Some programs participate and document in other record systems for service coordination e.g. Homeless Management Information System (HMIS) in the United States. In addition to any applicable privacy/sharing laws, be mindful when documenting in these systems. These record systems are often used to verify benefits for specific groups such as those with mental health or substance use disorders, and this information may be accessible to parties that the patient does not want to share with such as law enforcement. Ensure that the patient has appropriate consent to share their health information in these systems.

• Additional information in records can be used secondarily to demonstrate effort and the work being done, show positive outcomes, and utilized as a tool to advocate for support and growth by parent organizations.

• Programs that include trainees such as students or residents need to ensure that the same appropriate documentation standards are followed in street medicine e.g. attestations. See Appendix 3 for an example documentation procedure involving students.

Deciding What Services Need Charting

Street medicine care can often look different from hospital/clinic care and provide health services beyond the conventional understanding of “healthcare.” This can make it confusing about when to chart services; while all healthcare services in the traditional sense of the word need to be charted, it can be unclear for other encounters how much care is “enough” to count. It is equally important to keep in mind that requiring excessive documentation will likely overburden street medicine team members and lead to exhaustion and burnout.

Consider the example of a street medicine clinician who brings food and water to a patient and counsels them about their health. This example may be considered a health encounter even if no “exam” was done and no prescription medications were given. There are many conditions and social determinants of health that have International Classification of Diseases (ICD) codes that can be used for documenting, such as “inadequate drinking water supply” or “food insecurity.” Additionally, the act of considering and deciding not to prescribe a medication (or giving over-the-counter medication) is an example of medical decision-making and should be documented. The answer for whether to document will depend on factors such as billing, local regulations, and organizational policies. Street medicine programs should consider a guideline or policy to keep documentation appropriate and consistent.

Conclusion

Street medicine care has unique features and needs when it comes to record keeping, but these can be addressed with the thoughtful selection of an appropriate medical record system or adapting what is available for the home organization. Modifying conventional practices can lower barriers to care and allow the system to be a useful tool for team members and improve patient care.

Last Updated September 2026

References and Additional Reading

Beltrán, S., Cronholm, P. F., & Bartels, S. J. (2025). Adherence Labeling: Understanding the Origins, Limitations, and Ethical Challenges of "Diagnosing" Nonadherence. Annals of family medicine.

Cox, C., & Fritz, Z. (2022). Presenting complaint: use of language that disempowers patients. BMJ (Clinical Research ed.).

Feldman, C.T., Feldman, B.F., Hunt, J.J. (2019). HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient. OSF.

National Health Care for the Homeless Council (NHCHC). (2024, August 30). New Federal Regulation Establishes Street Medicine as a Reimbursable Model of Care.

Razaghi, M., Hafez, A., Farina, J. M., Scalia, I. G., Pereyra, M., Abdelfattah, F. E., Sheashaa, H., Awad, K., Lester, S. J., Ayoub, C., & Arsanjani, R. (2026). Transforming clinical documentation with ambient artificial intelligence (AI) scribes: a narrative review of technology, impact, and implementation. Cardiovascular diagnosis and therapy.

Vanka, A., Johnston, K. T., Delbanco, T., DesRoches, C. M., Garcia, A., Salmi, L., & Blease, C. (2025). Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study. JMIR Medical Education.

Appendix 1: Adapting an EMR for Street Medicine Use

The following table describes often encountered challenges and proposed solutions when adapting an EMR for street medicine use.

Appendix 2. Example Encounter Forms

The last two pages of the Record Keeping Guide PDF are example medical encounter forms. The first form is for a general medical encounter, while the second form is for a mental health evaluation. Again, while it is generally not advised to only use paper charting for documentation due to its limitations, these forms can be useful as field notes in conjunction with an EMR or for students to use to guide their evaluation. Some additional comments:

• Allow patients to only share their street name and strive to minimize required or “hard stop” information in order to lower barriers toward care.
• The location, demographics, and brief questions in the medical encounter form can be used as part of quality improvement/assurance programs to create metrics and evaluate provided care.
• Consider including an address and/or phone number field.
• Additional vital signs can include height/weight and last menstrual period.
• Chief concern is preferred over the historical chief “complaint” given its negative connotations (Cox, 2022).
• Aspects of a street-based mental health evaluation is discussed in the following webinar:
  Frye, L. (2026, February 9). Street-based Mental Health Assessment [Webinar]. Street Medicine ECHO. https://iecho.org/batch/BCH16935156972533FJUN2CZCF

Appendix 3. Example Documentation Procedure with Students

This example procedure involves students and uses a record keeping system that includes both paper notes and an EMR.

1. During street rounds, the student will act as a scribe to take notes on the history and physical exam as dictated by the clinician. Students will take notes on the Street Medicine documentation form.
2. Students will either give the hand-written notes to the clinician at the conclusion of the street outreach or type the notes and send it to the clinician through approved secure methods, depending on clinician preference. Typed notes must be sent to the clinician no later than noon on the Friday following the street outreach.
3. The outreach nurse is responsible for creating the encounter and entering vital signs and other vital information by close of business Thursday following the street outreach. In the event that the outreach nurse did not attend the outreach, the clinician will create the chart.
4. The clinician is responsible for completing notes in the EMR by close of business on Friday following the street outreach.

5. The clinician is also responsible for appropriately coding the note and recording the encounter under “Street Medicine Clinic” so that IT and the quality officer will be able to separate street medicine encounters from clinic encounters when analyzing and reporting data.