Social work assessment notes: a comprehensive outcomes-based hospice documentation system

Authors:
HANSEN Angela Gregory, et al
Journal article citation:
Health and Social Work, 40(3), 2015, pp.191-200.
Publisher:
Oxford University Press

This article describes the development of an integrated psychosocial patient and caregiver assessment and plan of care for hospice social work documentation. A team of hospice social workers developed the Social Work Assessment Notes as a quality improvement project in collaboration with the information technology department. Using the Social Work Assessment Tool as an organising framework, this comprehensive hospice social work documentation system is designed to integrate assessment, planning, and outcomes measurement. The system was developed to guide the assessment of patients’ and caregivers’ needs related to end-of-life psychosocial issues, to facilitate collaborative care plan development, and to measure patient- and family-centred outcomes. Goals established with the patient and the caregiver are documented in the plan of care and become the foundation for patient-centred, strengths-based interventions. Likert scales are used to assign numerical severity levels for identified issues and progress made toward goals and to track the outcome of social work interventions across nine psychosocial constructs. The documentation system was developed for use in an electronic health record but can be used for paper charting. Future plans include automated aggregate outcomes measurement to identify the most effective interventions and best practices in end-of-life care. (Edited publisher abstract)

Subject terms:
hospices, outcomes, end of life care, care planning, carers, patients, service users, psychosocial approach, needs assessment;
Content type:
practice example
Location(s):
United States
Link:
Journal home page
ISSN online:
1545-6854
ISSN print:
0360-7283

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