DOCUMENTATION REQUIREMENTS FOR PSYCHOSOCIAL …



DOCUMENTATION REQUIREMENTS FOR PSYCHOSOCIAL ASSESSMENTS REASSESSMENTS, AND SOCIAL WORK CONSULTS REQUIREMENTS

Updated October 29, 2007

Initial Inpatient Psychosocial Assessments

• Unit Specific-NICU, PICU, Hematology/Oncology, and the Rehabilitation Center. For these specific units, psychosocial assessments are completed automatically on all new admits to the units. The psychosocial assessments are to be completed/entered within 24 hours of admission.

• Physician's Referral-For new patients never seen by the hospital social workers, a psychosocial assessment must be conducted and entered into the chart within 24 hours of the referral.

• Social Worker's Clinical Discretion-Upon case finding by the social worker or referral by other members of the clinical team, the social worker may elect to conduct a psychosocial assessment. Upon completing the assessment, the assessment must be entered within 24 hours of the contact with patient and/or family.

Re-assessments

• For patients who are seen in Rehab, PICU, NICU and Hem/Onc patients, they will be seen weekly and updated in a progress note regarding their psychosocial situations.

• For high risk patients (i.e. child abuse cases, psychiatric cases), these patients are to have at least once a week contact documented in the progress notes.

• If upon patient’s needs, an assessment may occur more frequently appropriate to the needs of the patient.

Inpatient Psychosocial Assessments for Re-admissions 30 days

• Re-admissions 30 days-In the event that a patient is admitted to units where there are automatic referrals and assessment, a new psychosocial assessment will be completed and entered into the medical record within 24 hours of admission.

Transfer within the Hospital-Psychosocial Assessment

• Transfer from the ICU to the Acute Medical Care Units/Rehabilitation Center/Craycroft-In situations where a patient has been transferred to the Acute Care Units within 24 hours from admission to the ICU.

• Transfer from the Acute Medical Care Units to the ICU, Rehabilitation Center, or Craycroft-The psychosocial assessment is to be conducted and entered into the medical record within 24 hours.

• Transfer from ICU to Rehabilitation Center or Craycroft-In situations where the psychosocial assessment has been completed, a transfer note will be entered into the chart within 24 hours upon transfer notating any changes.

Ambulatory Clinics-Initial Psychosocial Assessment

• New CCS Clinic Patient-A patient who is evaluated for the initial multidisciplinary assessment is to have a psychosocial assessment completed and entered into the medical record within 5 working days.

• Annual CCS Re-evaluation-A patient who is being re-evaluated will received a new psychosocial assessment. The assessment is to be entered into the medical record within 5 working days.

• Non CCS New Admissions-At the request of the physician, a psychosocial assessment must be entered into the medical record within 5 working days.

Ambulatory Clinics-Psychosocial Reassessment

• CCS Visits-A patient who is seen for re-assessments will notate any updated information/significant changes within five working days within the calendar year.

Social Work Consults

• Requests for Social Work Services-In situations when the patient, family or staff are requesting concrete services or non recurring supportive services, a note is entered into the medical record within 24 hours of the contact with the patient, family or staff.

Under the emergent or urgent situations, the psychosocial assessment, re-assessment, or consult is to be completed within the same day of service.

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