Date
of Last Review 10/13/08
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 |
| Discharge 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 |
 | Family/significant others/guardian |
| Community resources |
| Treatment team |
| Progress in treatment |
| Discharge plans |
| Further discussion |
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 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.
