DOCUMENTATION REQUIREMENTS FOR SOCIAL WORK …



DOCUMENTATION REQUIREMENTS FOR SOCIAL WORK PROGRESS NOTES

The following describes the requirements for social work progress notes.

1. For patients who are followed for ongoing and continuous social work services such as our automatic referrals to Rehab, ICU, and Hem/Oncology, the minimum requirement is a once per week summary inpatient progress note.

2. For patients who we have been referred to social work services as a high risk patient, a progress note is to be entered once per week during the course of the patient's stay in inpatient care.

3. Inpatient progress notes are to be entered on the same day of contact. Ambulatory clinic notes are to be entered within five working days of the contact. For emergent situations, the note is to be entered as soon as possible.

4. Any note not entered within the established timeframe is to be documented as a late entry.

5. Progress notes that are handwritten must be legible and understandable and be signed. Progress notes entered into Meditech are to reflect the social worker's name, title, and phone number.

6. Progress notes completed by interns must be countersigned by the intern's supervisor.

7. For readmissions/transfers if a psychoscial assessment has been completed within the prior six months, a progress note may be used updating any changes since the last psychosocial assessment and a making reference to the previous psychosocial assessment.

9. Provision of hospital resources must be documented in the progress notes.

10. Any patient and family education is to be documented on the

Interdisciplinary Patient and Family Education Form and the

progress notes.

11. The request for a social work consult must be documented in the progress notes.

12. Discharge planning and care coordination are to be documented in the progress notes.

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