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S332 - Week 4

Professional Social Work Documentation
by

Tammi Nelson

on 3 February 2016

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Transcript of S332 - Week 4

Documentation
Practice

Practice Scenario
Darnyl is a 34 y.o., married, father of 3. Darnyl and his wife have been married 8 years and report being in a
mixed race marriage has made them a stronger family unit. Darnyl is close to his 3 children (ages 7, 4 and 1), coaching soccer and participating in the Parent-Teacher Organization at the 7 y.o's school.

The family is strong in their Baptist faith, participating in services and events. They are close to extended family and have a strong social support network.

Darnyl works 3/4-time as a Regional Sales Associate for a heating and Air conditioning company. His wife is a Preschool Teacher at the daycare center their children attend. Despite both working, they are struggling to meet the bills, which has recently been exacerbated by medical bills from the complicated birth of their youngest child and his reduced hours at work from fulltime to 3/4 time (due to company cutbacks to all staff).

Darnyl presents for assistance with financial pressures, fear of future foreclosure on their house, and health insurance.
Service Plan
In your groups, develop a Service Plan for Darnyl.

Goal
Objective, Interventions, timelines.
Intended outcome.
Social Work Consultation
Peer Supervision and Consultation
Identify key information about
the Client challenges.

Rule of 3: eliminate details that would
violate confidentiality

Identify skills used as the Social Worker
Identify challenge you need help with

Group must assist with ethical
problem solving.
Agenda
Familiarity with layers of Professional Documentation
Practice documentation based on Case Scenario's
Peer-Client engagement


Practice Skills

S332 - Week 4
Balancing Risks and Expectations of
Professional Social Work Documentation

Upcoming
Preparation for Next Week
Chang, Ch 12: Identifying Key Prolems and Challenges
Reading Log Wk 5- Ch 12

Canvas/Files – Week 5
Collins Ch 7-8

Entrance Ticket Week 5 bring to class.

Complete HW 12.2, 12.3, 12.4, 12.5, 12.6, bring a copy to class.
Peer-Client 1st attempt Initial assessment
(Form is in Modules)
----- bring PRINTED copy to class for Peer-review
Initial Assessment
Initial Assessment- Worth 10 pts
Interview your Peer Client to gather answers to key areas of information necessary to successfully begin working with the Client. Bring a printed copy to class next wee.

Social Workers type the form using professional language, grammar and sentence structure.
Attending to pronouns and ensuring you, as the Social Worker, are not mentioned in the document.
Service Plan
Worth 20 pts
Students will revisit the Initial Assessment and develop a plan to address the goals set by their peer Client. The form will be completed and submitted in Canvas by the assigned due date.
Fishbowl
Client's role play Darnyl.
Social Workers conduct an initial meeting, gathering information to assess his needs and challenges, strengths and potential options.

Peanut Gallery: In groups, write
your professional Initial Assessments

Develop a list of questions for which you still need answers.
New Darnyl - & - New Social Worker
Figure out the answers to group questions.
What are your group findings?
What do you need to research to assist Darnyl?
Social Worker Feedback
What did our Social Worker do well?

What could our Social Worker do better?

Way to go Social Worker!
Professional Documentation
Initial Assessments
Demographic information
Person-Environment-Situation
Beginning and duration of problem, attempts to resolve, confounding issues. Strengths, limitations, and motivation.
Progress Notes
Current needs, interventions, progress toward goals, plans.
Client Rights, Registration, Consent

BIOPSYCHOSOCIAL ASSESSMENT

1. Presenting Problem(s) and Requested Service(s):
• What is the client’s presenting problem/why are they here? (in client’s own words when possible)
• Describe precipitating events:
What service(s) is the client asking for?
2. Lifespan/Developmental History:
• Health at birth:
• Developmental milestones: Within normal limits (use this box for adults only, complete section if child)
• Special services received during lifetime:
Other lifespan/developmental issues: (include mid-life, senior/elder, other issues)
3. Education and Occupation:
• School currently attending, if applicable: ____________________________________________ Grade:_____

• Education history: (include learning problems, school issues). Highest grade completed: _________________
• Occupation and employment history: (present and past, include # of years worked, and reasons for period of unemployment)
• Occupational skills/training:
4. Family of Origin History:
• Family’s current and past psychiatric history:
• Family’s and client’s physical/ sexual/ emotional abuse history:
• Family’s substance abuse/ abuse history:
5. Client’s Current and Significant Past Social Supports, Family Supports, Significant Relationships, Religious and Spiritual Supports/ Affiliations:
6. Other Agencies/ Systems Client in Involved With or is Receiving Services from, i.e., Dept of Rehab., CalWORKS, ASOC, etc.: (include the name of the agency and primary contact person-ATTACH RELEASES)
7. Clients Legal History (ATTACH RELEASES)
Informal Probation Formal Probation Parole Child Welfare Services
Conservatorship D.U.I. Restraining Order None reported
(Describe and, if currently involved, give name of probation officer, parole officer, or case manager and estimated start and end dates)

8. Client’s Substance Use: (alcohol and other drugs, check all that apply)

Caffeine Alcohol Stimulants Barbiturates
Tobacco Inhalants Sedatives Methamphetamines
Over-the-counter medication Hallucinogens Tranquilizers Opiates
Prescription medication Marijuana Cocaine Methadone
Other; please identify:

Substance Age of 1st Use Amount/Frequency Duration of Use Date of Last Use Period of Heaviest Use Amount Used in Last 24 hrs.









• Does the client have a history of withdrawal, DTs, blackouts (loss of time), seizures, etc.? Yes No



• Ask the client “What happens when you stop using?” What is the response?



• What is the longest period of sobriety? ___________ When? _______________________________________

• Has the client received treatment for drug or alcohol issues? Yes No (ATTACH RELEASES)
(if yes, list in-patient providers, out-patient, providers, services received, dates of service; and outcomes)

9. Client’s Mental health Services History: (ATTACH RELEASES)
• Current and past psychiatric history:
• Current service provider(s):
• Past service provider(s): (include in-patient, out-patient; provider names, dates, therapeutic interventions and outcomes)

10. Medical History: (document significant past and resent medical conditions, including allergies) (ATTACH RELEASES)
Client reports no outstanding medical problems
Client reports no known allergies
Client reports following medical conditions: ___________________________________________________

Primary Care Physician’s name and phone #:__________________________________________________________

Date of last physical examination: ___________________________________________________________________

List of alternative treatments/therapies: (i.e. biofeedback, acupuncture, hypnosis, etc.)


11. Medication History: (ATTACH RELEASES)
• Current psychiatric medications: None reported by client
Drug Name Dose/Frequency Benefit/Side Effects Prescribed By: (Dr’s Name) When Prescribed? When is Next Refill Required?

• Past psychiatric medications: None reported by client
Drug Name Dose/Frequency Benefit/Side Effects Prescribed By: (Dr’s Name) When Prescribed? When is Next Refill Required?

• Other medications: None reported by the client
(include non-psychiatric prescriptions and alternative medications, i.e. homeopathic, herbal remedies)
Drug Name Dose/Frequency Benefit/Side Effects Prescribed By: (Dr’s Name) When Prescribed? When is Next Refill Required?


• Medication allergies or adverse reactions: None known—per client report
Drug Name Reaction

13. Current Symptoms/Problems: (rate severity and duration for each)
Severity Rating: 1= Mild 2= Moderate 3=Severe
Key:
Duration Rating: 1=Less Than 1 Month 2= 1-6 Months 3=7-11 Months 4= More Than 1 Year

Severity Duration Severity Duration
1. Anxiety ________ ________ 15. Bizarre Ideation ¬_______ _______
2. Panic Attacks ________ ________ 16. Bizarre Behavior _______ _______
3. Phobia ________ ________ 17. Paranoid Ideation _______ _______
4. Obsessive Compulsive ________ ________ 18. Gender Issues _______ _______
5. Somatization ________ ________ 19. Eating Disorders _______ _______
6. Depression ________ ________ 20. Poor Judgment _______ _______
7. Impaired Memory ________ ________ 21. Lack of Support System _______ _______
8. Poor Self Care Skills ________ ________ 22. Poor Interpersonal Skills _______ _______
9. Loss of Interest ________ ________ 23. Conduct Problems _______ _______
10. Loss of Energy ________ ________ 24. School Problems _______ _______
11. Sexual Dysfunction ________ ________ 25. Family Problems _______ _______
12. Sleep Disturbance ________ ________ 26. Indep. Living Problems _______ _______
13. Appetite Disturbance ________ ________ 27. Unusual Body Movements _______ _______
14. Weight Change ________ ________ 28. Other: ______________ _______ _______

Please describe symptoms/ problems above in detail:

14. Mental Status: (please describe client’s physical appearance, motor behavior, eye contact, mood, affect, speech pattern, thought processes, thought content, audio/visual/tactile hallucinations, intelligence, insight, judgment, and orientation)

15. Assessment of Risk:
a. Current risk factors: (check all that apply)
• Suicidality: None Ideation Plan Intent w/o means Intent with means
• Homicidality: None Ideation Plan Intent w/o means Intent with means
• If risk exists, client is able to contract no harm: Self Others
• Impulse control: Sufficient Moderate Minimal Inconsistent Explosive
• Substance abuse: None Abuse Dependence Unstable remission
• Medical risks: No Yes If “Yes”, explain:_________________________________

b. Risk History: (Explain any significant history of suicidal, homicidal, impule control, medical or substance abuse behavior that may affect client’s current level of risk or impairment to functioning. Include description of plan/ideation/intent checked above)


16. Describe Client Strengths in Achieving Case Plan/ Treatment Goals:

17. Summary of Findings/ Formulation: (identify problem areas and underlying dynamics. Include information used to make differential diagnosis)

18. Recommended Services: (check all that apply.)
Community referrals made, no further services needed.
Medication assessment By Primary Care Physician By ASOC or CSOC Psychiatrist
Individual therapy, frequency recommended is_____times per month. Brief therapy Long-term therapy
Family therapy
Collateral, describe reason:___________________________________________________________________________
Group, specify type: ________________________________________________________________________________
Testing, specify type: (i.e. Corner’s, Beck, etc.) ____________________________________________________________
Day rehab/ treatment
Other, specify: ____________________________________________________________________________________

19. Services Provided:
a. If community referrals were made, please describe: None


Assessment completed by:

Practitioner Signature:
(Include licensure, degree, or job title): ____________________________________________________Date:_________________

Print Name: ____________________________ Work Unit/Organization: ________________________ Phone # ______________
Client Registration

Client Full Name: Social Security Number

Home Address: City/State/Zip:

Phone: Cell Phone:
Alternative Phone:

Client or Guardian Employer: Phone Number:

Student Enrollment Location: Student status:

Family Physician:
Emergency Contact: Emergency Contact Phone:

INSURANCE (Responsible Party)
Name of Insured: Relationship:
Occupation: Phone:
Employer Address: Phone:
Insured's SS#:

Spouse's Name: SS#:
Spouse's Employer: Phone:

Insured's Primary Insurance Co: ID Number:
Group Number:
Secondary Insurance Co: ID Number:
Group Number:
Workmen's Comp Co

Billing and Insurance Policy:
I authorize the use of this information on all insurance submissions.
I authorize the release of information to my insurance company(s).
I understand that I am responsible for the full amount of my bill for services provided.
I authorize direct payment to my service provider.
I permit a copy of this to be used in place of an original.

Name (Print): Signature:
Date:
Case Management, Inc.
Progress Note
DATE: __________ Start time: ________________ Stop time: ________________ Units: _______
Appearance: WNL Unkempt Dirty Meticulous Unusual
Behavior: WNL Guarded Withdrawn Manipulative Cooperative
Mood: WNL Depressed Euphoric Anxious Irritable Angry
Safety: Danger to self or others? Yes / No Safe to be home? Yes/ No
Service goals addressed this session: ________________________________________________
Intervention and/or teaching:
________________________________________________
Client response and participation:
________________________________________________
Plan:
________________________________________________
Date/time of next meeting: ________________ Location of next meeting: ________________________
_________________________________ ___________________
Signature Date
Evaluation and Treatment Consent
The below named Client is presenting for services associated with an autonomous and individual need. As the client, or guardian thereof, I authorize the evaluation and services identified below. As the client, or guardian thereof, I have the right to request information concerning the evaluation, treatment, service plan and discharge planning. I have a right to identify who receives confidential information, signified in my express consent through a Release of Information agreement. I have the right revoke a release of any information at any time.
Client Name (Printed): ______________________________
Signature: ________________________________________ Name if Guardian: _________________
Client Rights & Responsibilities
Client's Rights
Every effort is made to respect individuals who come to Children's Bureau, Inc. for services and to protect clients' rights. As a client, you have a right to:
•Receive confidential services.
•Review your record, except those protected by law.
•Ask questions about any services or procedures.
•Request correction of information you believe to be wrong or add written material of your choosing.
•Review a detailed copy of clients' rights.
•End counseling/services at any time, unless court-ordered.
•Know that there are certain situations in which the agency and your worker are required by law to reveal information obtained during counseling without your permission.
•If you threaten bodily harm or death to another person.
oIf you reveal information about child abuse or neglect.
oIf you violate a court order.
oIf your counseling is court-ordered.
oIf your worker or records are subpoenaed by the court; and if you are a minor, certain information may need to be shared with your parent/guardian to get the additional help you need.
You are encouraged to comment on our services and to inform us of unmet needs in the community.
Working with Children's Bureau, Inc.
In order to get the full benefit of the service in which you are involved, we expect that you will:
•Keep appointments.
•Make an effort to involve yourself in counseling, group or other activities.
•Communicate openly and honestly.
•Complete contracts entered into with worker/agency.
Clients of the agency are expected to participate fully to the extent that they are able in the Goal Assessment, Treatment and Discharge process. Clients will only be involuntarily discharged from service for the following reasons:
•Assaulting or threatening behavior or language toward a worker or worker's property.
•Continued use of drugs or alcohol with no commitment to treatment when recommended.
•Refusal to adhere to specific components of a court-ordered service.
•A pattern of failure to show up for appointments (usually 30 days).
•Movement out of a geographic service area (Children's Bureau, Inc. will make every effort to provide, in writing, referrals for services from other agencies).
•Treatment no longer warranted by circumstances.
Grievance Procedure
The staff at Children's Bureau will make every effort to help you resolve the problems that brought you to the agency. If you are not satisfied with the services you receive, you should talk with your assigned social worker/counselor. The social worker/counselor is expected to schedule an appointment for you within two weeks. If the grievance cannot be resolved with your social worker/counselor, the following steps may be taken:
STEP 1:
Talk to your social worker/counselor's program supervisor (the appointment should be scheduled for you within two weeks).
STEP 2:
Make an appointment to talk to the vice president responsible for the program (the appointment should be scheduled for you within two weeks).
STEP 3:
Send a written request to the president/CEO for a review of the problem (a response should be received from the president/CEO within 30 days).
Treatment Plan
Goals
Objectives
Interventions
Plans
Intended outcomes
Dates, Providers,
Client Signature
Service Plan

Client Name: _____________________________________ Date: ____________

Goal: __________________________________________________________________

Objectives: Interventions: Date of Completion:
1.

2.

3.


Intended Outcome: _______________________________________________________

___________________________ ______ ______________________ ______
Client Signature Date Provider Signature Date
3rd Meeting with Darnyl
Darnyl is working with a Consumer
Credit agency and the utility companies. His medical debt has been reduce by 90%.

Darnyl indicates that he needs more assistance. Even with debt reduced, he is concerned about the future of family finances due to his reduced salary at work.

Social Worker: Evaluate progress, identify strengths and identify Darnyl's future plans.

Groups: Write a professional progress note.
SOAP

Subjective, Objective, Assessment, Plan
Client presents today, reporting progress following referrals to consumer credit and utility advocates. Client indicates that his hospital debt has been 90% forgiven and his utilities are on a fixed plan.
Client appears happy with the progress and open to additional work on financial stability goal.
Client identified interest in taking advantage of educational assistance and job resources.

Client was provided referrals to Educational Assistance Program and Work One. Client will follow up with both and return in two weeks.
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