Written by Elizabeth Cairns, Mobilize Recovery Special Projects, and reviewed by Code Recover Peer Advisors, August 2026

Peer recovery support specialist Spencer Costello talks about considerations for training new peers, protecting patient privacy, and how to make data collection flow like a conversation.

If It Isn’t Charted, It Didn’t Happen

In the medical world, the electronic health record (EHR) is the source of truth. Documentation might feel like a chore, but it is actually one of your most powerful advocacy tools. When you write a note, you are doing more than just recording a conversation; you are showing the clinical team exactly how your work moved the needle for the patient. Good documentation ensures that the next person who sees the patient, whether it’s a nurse on the floor or a provider at an outpatient clinic, knows the plan you worked so hard to build.

The DAP Note: Keeping It Simple

You don’t need to write a novel. Most peers find success using the DAP format (Data, Assessment, Plan). This structure is easy for doctors and nurses to scan quickly:

• Data: What did you observe and what did the patient say? Stick to the facts.
  • Example: "Met with patient at bedside. Patient reported feeling exhausted and expressed interest in starting MOUD. Patient currently experiencing tremors and nausea."
• Assessment: What is your professional peer perspective on the situation?
  • Example: "Patient appears motivated for change but identifies lack of transportation as a primary barrier to follow-up."
• Plan: What are the next steps?
  • Example: "Coordinated warm handoff with [Clinic Name] for tomorrow at 10:00 AM. Provided bus pass and confirmed pharmacy has medication in stock. Will follow up with patient via phone in 24 hours."

Use Objective Language

As a peer, you want to be authentic, but your documentation must remain professional. Avoid judgmental language, and try to be factual.

• Instead of: "Patient was being difficult and didn't care about their health."
• Try: "Patient declined to discuss treatment options at this time, citing a desire to leave the hospital immediately."
• Instead of: "Patient is an addict."
• Try: "Patient is an individual with Opioid Use Disorder (OUD)."

Documentation Demonstrates Value

Documenting your interventions, like finding a shelter bed, coordinating a ride, or conducting a warm handoff, provides data that justifies the peer program's existence. Your notes are a tool to bridge the gap between clinical stabilization and long-term recovery, and will help the hospital track the success of its programming.

Peer Tip: Always double-check that you are in the correct patient’s chart before you start typing. In the fast-paced ED, it is easy to make a mistake.