What a decade as a military medic taught me about documentation and behavior change

Before public health, I spent nearly ten years as a military medic. Coaching sessions in a primary care office look nothing like a field aid station, but the habits that keep patients safe there are the same ones that make coaching notes defensible here.

1. If it isn't written down, it didn't happen

Every medic learns this early. Care you can't show on paper can't be continued, reviewed or defended. In coaching, that means actual start and stop times, the modality, what the patient said, and what you agreed on, written for this patient in this session. Cloned notes are the paperwork version of skipping a reassessment.

2. Know your scope, and your handoff

A medic's most important skill is knowing what is beyond them and getting the patient to the next level of care fast. Coaching has the same boundary. New symptoms, medication questions or safety concerns go to the supervising practitioner, and the note shows that you sent them. Medicare paying for coaching does not expand anyone's scope.

3. Standard procedures free you to focus on the person

Checklists aren't bureaucracy; they're how you avoid missing the obvious when you're busy. A coaching note template should work the same way: prompt for every required field so your attention goes to the conversation. The template supplies the structure, never the content.

4. Mission beats motivation

Service members don't run on motivation alone; they run on a clear mission, a plan and a team. Patients are similar. "Walk with my grandkids without stopping" is a mission. A SMART plan and a check-in date are the operation. Identifying who supports the patient, their unit, is often the strongest lever you have.

5. Respect the chain of command

In incident-to coaching, the supervising practitioner directs the plan of care and bills the service. Good coaches make that relationship easy: clear notes, timely referrals, no surprises. But a chain of command also has to follow the rules above it. If an instruction conflicts with CMS, your MAC or state law, escalate to compliance rather than going along with it.

For coaches working with veterans

I wrote a separate guide on coaching veterans in civilian practice, covering military culture, VA Whole Health and the crisis-line protocol every handout should carry.

Educational only; not legal, billing, coding or clinical advice. Your supervising practitioner's and organization's policies come first, and they must comply with CMS, your MAC and state law. CPT® is a registered trademark of the American Medical Association.