of Last Review 01/04/2013
SME: Director of Social Services
Social Service Clinicians use the electronic case management progress note forms to document their work with patients:
Initial progress note
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
Progress in treatment
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.
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.
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
See Legibility and Unacceptable Abbreviations
Related to regulatory standards
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.