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Social Service Case Management Progress Notes

Introduction

Date of Last Review 01/04/2013
SME: Director of S
ocial Services

Social Service Clinicians use the electronic case management progress note forms to document their work with patients:

Initial progress note

Discharge note

Information included

The screen provides a space for the date and time that the note is added to the medical record as well as spaces to document the following:

Contacts with patient

Contacts with others significant to treatment and discharge planning

Family/significant others/guardian

Community resources

Treatment team

Progress in treatment

Discharge plans

Further discussion

When completed

Initial Progress Note completion:
The Social Service Clinician must complete the Initial Progress Note within 72 hours of the patient's arrival to a given treatment unit.

Summary Note completion:
The Social Service Clinician completes the first Summary Note by the end of the fifth day of a patient's stay. S/he completes subsequent Summary Notes are at least every fifth day thereafter.

Discharge summary information:
The discharge summary informationis found in the multidisciplinary discharge document. The Social Service Clinician my use the "Summary Note" format when the discharge coincides with the need for a weekly summary. Otherwise, s/he may use the following standard Progress Note format:

Date, Time, Discipline, Discharge Summary Note

A listing of arrangements as outlined above

Signature and credentials of the Social Service Clinician

Quality requirements

See Legibility and Unacceptable Abbreviations

Related standards

Related to regulatory standards

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Harris County Psychiatric Center University of Texas Health Science Center