Medical Social Work Assessment Page 1 End Time in: Time Out: Visit Duration: Time not recorded on Visit Note Caregiver Resources Primary Caregiver: Phone: Other Phone: Relationship: Address: Hired Attendant (name/agency): Phone: Caregiver Abilities: nmlkj Willing nmlkj Hesitant nmlkj Able to assist with care nmlkj Unable to assist with care Availability: nmlkj 24 hour nmlkj Limited Availability Comments: Health History: Names of Additional family members/significant others: Name Address Phone Other Phone 1. Relationship 2. 3. 4. 5. 6. Caregiver Resources Comments: Patients Social History Spouse Length of Marriage # of Children Marital Status Education Level How patient came to hospice: Spouse/Children Summary Pets How long at current home: Patient Social History Comments:
Medical Social Work Assessment Page 2 Patient Physical Assessment Pain/sx management needs: Environmental Safety Concerns: Patient Response to Illness: Physical End of Life Goals/restrictions (pain mgt, anxiety, etc): Oriented to Person Is memory adequate for: Place Recent Events: Time Other Confused Somnolent Remote Events: Non Responsive Appearance nmlkj Clean nmlkj Unclean nmlkj Well groomed nmlkj Unkempt Financial/Legal Assessment DPOA in place? DNR/POST in place? Funeral Arrangements made? If no, need assistance with completion Funeral Home Phone Advance Directive: Designee: Reimbursement Source: Need Assistance? Need Assistance? Yes No Medicare Medicaid Referral to Community Resource Comments Private Insurance None SSI SSD nmlkj Medicaid Other nmlkj Food Purchase Mortgage/Rent Medications Preferences Burial Cremation Utility Payments Other Bills Spiritual Assessment Church Involvement? Church/Denomination Membership Name of Pastor
Medical Social Work Assessment Page 3 Risk Assessment Check Yes or No or Unknown For each question a Yes response indicates risk potential 1. Domestic violence? 2. Abuse, neglect, exploitation? Specify 3. Addictions? 4. Suicidal Ideation? 5. Mental Illness? 6. Recent Diagnosis? 7. Recent Terminal Prognosis? 8. Rapid Change in Level of Care? 9. Short Prognosis? 10. Health Problems (Family)? 11. Financial Stress? 12. Poor Support System? Describe any other risks: Bereavement Risk Assessment nmlkj 1 No Risk nmlkj 2 Low Risk nmlkj 3 Moderate Risk nmlkj 4 High Risk nmlkj 5 Extreme Risk Comments: Volunteer Program Referral to Volunteer Program? Comments:
Medical Social Work Assessment Page 4 1. Coping\Knowledge New Ongoing Resolved Identified Problems Interventions Reoccurrence Assessed/No Problem Anxiety Role Change Isolation Depression Anger Needs community resources Concerns with Family Coping Family has conflict over DNR Patient has conflict over DNR No Access to Spiritual Support Spiritual Distress End of Life Planning Interpersonal Conflict Change in body image Suicidal Ideation Patient desires DNR, but not completed Grief Loneliness Communication deficit Educate Patient Caregiver SW to assess and develop POC Chaplain to assess and develop POC Explore/access community resources for: Facilitate life review SW to follow up on DNR disease effect on Coping/Knowledge Supportive Listening Report abuse to APS/CPS Encourage and monitor pt/family decision making Encourage Expression of Feelings Volunteer Requested For: Goals Patient Caregiver verbalizes/demonstrates understanding of disease effect on Coping/Knowledge Family demonstrates ability to handle stress and to make appropriate decisions End of life planning including funeral plans are complete prior to death Interpersonal conflict improved or resolved Identified coping/knowledge problems no longer interfere with quality of life Family able to do long range planning Community resources are accessed Pt/cg no longer abused Designated POC Established Spiritual issues resolved Pt/CG comfortable with DNR
Medical Social Work Assessment Page 5 2. Anticipatory Grief/Bereavement Assessment New Ongoing Resolved Identified Areas of Support Interventions Reoccurrence Assessed/No Problem Progress is hindered in the grieving process Patient Family Denial of terminal prognosis Patient Family Educate Patient Caregiver disease effect on Grieving Anticipatory/Bereavement Encourage expression of feelings Encourage verbalization of changes resulting from death of patient Invite to standing supportgroups Identify support systems Volunteer requested for: Daily stressors that accompany a terminal diagnosis Patient Caregiver Goals Patient Caregiver verbalizes/demonstrates understanding of disease effect on Grieving Anticipatory/Bereavement Patient will proceed thru stages of grieving with ultimate acceptance of loss Caregiver will proceed thru stages of grieving with ultimate acceptance of loss Patient Caregiver approaite decisions. able to handle stress and make Continued acceptance of terminal prognosis
Medical Social Work Assessment Page 6 3. Spiritual Concerns New Ongoing Resolved Identified Problems Interventions Reoccurrence Assessed/No Problem Patient has conflict regarding spiritual issues Patient wants rites of the church Family has conflicts to resolve Family/pt. requests prayer/scripture reading and/or spiritual discussion Educate Patient Caregiver Provide spiritual counseling Contact requested clergy Volunteer Requested For: disease effect on Spiritual Concerns Facilitate conflict resolution Support Group Referral Volunteer Requested For: Goals Patient Caregiver verbalizes/demonstrates understanding of disease effect on Spiritual Concerns Verbalize benefit of spiritual support Verbalize acceptance of terminal status Reconcile state of relationships Verbalize resolution of moral/ethical dilemmas Summary
Medical Social Work Assessment Page 7 4. Coordination of Care Comments (Included in document flow) - This Visit Coordination of Care Summary - Previous Documents