ࡱ> HJG bjbjdd 0(tt$-t     )-+-+-+-+-+-+-$/1O-O-  d-   )-)-*, ׶&  e+-z-0-{+622,,2,dhTPO-O--2t }: 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 patients needs, an assessment may occur more frequently appropriate to the needs of the patient. Inpatient Psychosocial Assessments for Re-admissions <30 days and >30 days Re-admissions <30 Days-In the event that patient is admitted to units where there are automatic referrals and assessments, the previous psychosocial assessment will be utilized. A note will be entered into the progress note referencing the previous psychosocial assessment and any updated information is noted and entered into the medical record within 24 hours of the admission. In situations when a psychosocial is being requested by the physician or clinical team, the previous psychosocial assessment will be utilized and an updated note is entered into the chart within 24 hours of referral. Re-admission >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. 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