RN CASE MANAGER - suncrestcare.com Work and... · 2.) Attend all IDT’s required unless you notify supervisor. 3.) Call the Primary contact for patient to ensure needs and expectations

SOCIAL WORKER

CHARTING GUIDE

A WEEK IN THE LIFE OF A SOCIAL WORKER

A week in the life of a social worker can take on many forms. However, there are things to be sure to do weekly.

1.) We have a goal to see 20 patients per week2.) Make sure all new admits have an assessment done within

the first 5 days of admission(this is MEDICARE REGULATION.)3.) If any patient goes on STARS be sure to see them within

24hr, and communicate with team when you will be there.4.) Be available to assist with admissions by talking to family

and going over consents.5.) Make sure prep notes are completed for patients being

discussed by 8AM day of IDT. NOTE: if you have a patient that is up for Recert you must have the recert note in with new orders and updated care plan by the end of the day Thursday the week prior to IDT.

A Monthly Snapshot

Over the course of the month there are things that need to be completed as well.

1.) See all your patients according to the frequencies that have been assigned to them. As Social workers we know that some of our patients may need to be seen 2-3x/month and some may only need to be seen 1x/month depending on level of support needed. This is originally determined at admission and then re-assessed as needed through length of stay.

2.) Attend all IDT’s required unless you notify supervisor.3.) Call the Primary contact for patient to ensure needs and

expectations are being met. (you do not need to make call if main point of contact is present during a visit.)

4.) Collaborate with facility staff to ensure they have the support needed to care for patient emotionally.

5.) SW may be asked to attend care conferences when our patients are being discussed.

REMINDERS FOR DAILY TASKS

CHECK THE ON CALL REPORT EVERY AM FOR ANY CONCERNS

FOR YOUR PATIENTS. F/U ON ANY CONCERNS IS YOUR FIRST

PRIORITY. IF IT IS NOT AN URGENT MATTER, ACKNOWLEDGE THE

ON-CALL REPORT THAT YOU ARE AWARE AND ARE WORKING

ON THE CONCERN. IF ADDITIONAL INFORMATION IS NEEDED

FROM ON-CALL RN, PLEASE CALL THEM PRIOR TO 0830.

UPDATE FAMILY/PRIMARY CAREGIVERS OF ANY CHANGES BIG

OR SMALL, AND HOWEVER OFTEN THEY WANT TO BE

CONTACTED (SUNCREST DES MOINES STANDARD PRACTICE IS A

MONTHLY AT MINIMUM). DOCUMENT COMMUNICATION NOTE

OR VISIT NOTE FOR FAMILY/CAREGIVER CONTACTS.

COMMUNICATE WITH KEY INDIVIDUALS IN YOUR FACILITIES FOR

ANY CHANGES OR ORDERS YOU OBTAIN DURING YOUR VISITS.

SUNCREST POLICY IS FOR ALL VISITS TO BE COMPLETED WITHIN

24 HOURS.

COMMUNICATE WITH THE HOSPICE TEAM WITH ANY CONCERNS

OR CHANGES IN ANY PATIENT INFORMATION

INITIAL ASSESSMENTADMISSION VISIT

Has to be completed within 5 days of admission, Admission day is day 1. This is

a MEDICARE regulation.

Complete assessment of psychosocial and emotional needs along with social

history. This may be done with patient and/or family/primary contact

Complete Bereavement Risk Assessment In the Assessment

Write up prep note for patient during their week.

Chart on all care plan interventions

Information to gather during assessment:

If not the patient—you can ask loved one if patient would enjoy a visit and

how would we typically find patient. How communicative is the patient?

Career: this may give us information about how patient operates (i.e. if

they always worked night shift it may not be effective to make morning

visits

Interests/Hobbies aside from work: will help relate to patient and build

relationship. May also ask about faith/religion.

Background: Is patient from around here originally? What is patients

marital status? Were there children? How many? Are they still living? How

was family relationship?

Family structure: How well does patient/loved one feel they are being

supported by rest of the family? (This will help us start to examine current

bereavement risks)

Veteran Status: Did patient serve? If yes, what branch? During what war?

Are they enrolled in VA? Any family members that are also veterans?

Funeral Home: If one has not been selected/planned, we can care plan

this and assist families with setting this up.

Living situation: Want to get an idea id a potential transfer may need to

occur while on service.

Financials: To be assessed based off flow of conversation—if family

needing additional care for patient would need to know if there are any

funds to do so.

EXAMPLE OF ADMISSION PREP NOTEENTERED UNDER COMMUNICATION

NOTES – PREP NOTES

The first prep note for a patient, MSW’s are able to use the narrative from their initial

assessment.

DISCIPLINE ORDERS

All patients, who are accepting of Social Work

services will receive orders for visits depending on

the needs of patient and family

Level 1: Low needs (funeral may be planned,

family visits often, and verbalizes not needing much

support. OR Family has low needs and patient

minimally responsive to visits). Order = 1x/month 2

PRN

Level 2: Moderate Needs (may need some

help with plans or just enjoys company, may be a

risk for bereavement that we would want to

address before patient decline, lots of scenarios

here) Order = 1-2x/month 2 PRN

Level 3: High Needs (may need a move, lots of

support with funeral planning, Patient or family has

a lot of anxiety about hospice, etc.) Order= 2-

3x/month 2 PRN.

Discipline Orders/Frequencies

These must be done by Thursday the week prior to discussing

patient at IDT

Update all target dates for goals on care plans.

Update order frequencies .

Complete a hospice recertification assessment to replace the

hospice follow up visit for your first visit of the week.

Write a recertification prep note for the patient the week to talk

about them during IDT, detailing all of the ways the patient has

declined during the certification period (I.E. visible weight loss,

ambulation declines, sleeping more, eating less, etc.)

Ensure that patient continues to remain appropriate for

hospice. If questioning, make sure to discuss at IDT weeks prior

to recertification date to ensure proper time to look into

potential decline or custodial care.

Recertification's

Put in an order to assess and evaluate. After assessment is

completed you can add your orders for continued follow up.

Frequency orders are based off of the level of patient and needs

that the patient and family have.

Low would be 1x/month with added PRN’s in case something comes up

Moderate would be 1-2x/month with added PRN’s

High would be 2-3x/month with added PRN’s

It is important to remember that a patient could start at a High level and

then drop to moderate or low depending on the needs.

STARTING IN BRIGHTREE

Find the patient under ALL Patient and pin, Sync again.

Click on pin then Sync

Login to Brightree

SYNC

Reviewing the Chart

After you sync find the patient again under on device Then Click on the patient’s name. Below is the screen you will see.

Pt Name

Pts Name

Now to find the patients “chart” in Brightree…. Click on the three lines by the patients name…

You will find physicians, Organizations, Personal contacts,

You will find DX, add allergies

Patient info is the only thing you can edit on this page- tap

on patients name and you can edit.

Adding assess and evaluate order

Tap on Discipline Orders

Tap on Add Discipline Order

Adding Assess and Evaluate Order Continued

After Click “add discipline order” this is the screen you will get.

Discipline will be MSW – Start date will be the current date and end no later than 5 days after admission. Order Type: Assess and Evaluation

New Order Group – Plan Of Care

ANYTHING WITH THE GOLD BOX YOU HAVE TO COMPLETE. Once all Gold box complete choose DONE

You will choose NEW ORDER GROUP- On

Admission

Adding Assess and Evaluate Order Continued

After the order is done it will be present on your home screen for review to submit. To get to the home screen you choose the home icon.

Click on the order, Click Submit.

THEN SYNC to make it active…

Discipline Orders

SW, CH, Music Therapy and Massage Therapy are responsible for own orders.

Choose Add Discipline Order

New Order Group= From next drop down select

PLAN OF CARE

Discipline= CHOOSE APPRORIATE DISCPLINE Start Date= DAY AFTER

ADMISSION

Frequency and Range- 1-2x month (only can have a range of 1-2.

Duration- 13 weeks- or how many weeks in certification period

PRN- 1-2 PRN and PRN Reason. (exp: psychosocial needs)

After you choose done, the order has been created.

You Now need to click on the house to take you to

your screen. Order will appear in the upper right

corner under TASKS, click on that, submit and sync.

This will then activate your Order

Orders Continued

Discipline-

Choose

appropriate

Clinician- choose

the appropriate

clinician

Choose two days

a month and the

visits will show up

on the right side…

Make sure that

your start date

and end date

are within the

certification

period.

THEN DONE

Social Work CARE PLANS

Social work care plans will reflect social work needs with

patient. They can include offering grief support, connecting

patient and family to resources, end of life planning, and

facilitating life review. (among many others)

Social work care plans will pop up in Brightree when

completing a visit note and you need to accurately chart on

what you did. You may not chart on each part of the care

plan with each visit but you must discuss in your narrative what

was completed in detail.

CARE PLANClick on patient name, patients chart, then

choose care plan

Click on the area you are building and add the interventions.

Choose Hospice

After you choose hospice then you can specify what you want. EX-

Spiritual Needs, Diagnosis Specific(cancer, Alzheimer’s),

Follow up visit notes A Social workers visits can take many shapes. There may be a need

to assist family with paperwork. There may be a need to be an emotional support to patient and/or family. There may be a need to be a calm assuring presence to patient. There may be a need to discuss and calm fears about the dying process. Some of these things may be obvious and brought up with admission so we can put it in a care plan, sometimes they come up sporadically. It is important to have those conversations to ensure all parties are prepared for the passing of our patient.

When we do our visit notes we try to be sure to accurately show what we are doing at each visit. Ensuring we chart on the care plan and then elaborate in the narrative note what was completed and how to support patient and family ongoing.

Be sure to note any significant changes in decline.

To add a visit to your schedule:

Select the calendar icon on the upper left of iPad

Select – Add a visit

Enter patient name

Tap on the order field – a drop down box with order will come up

Select the order you want to use

Done

Sync

Once the sync is done you will see the schedule screen with the patient on the left

Select patient by tapping their name

Add Visit Note will appear, tap the box, select Hospice Follow Up Visit ( If this was the initial visit you would have selected Hospice Initial Assessment)

Done

First screen to show is the Administrative Screen

Enter the time in for the visit

Service Code Box – MSW Routine Follow Up Visit (If this was initial you would select MSW Assessment)

Begin working on your prep notes the week of IDT. This must be completed on all patients being discussed during that week.

Prep notes must be completed and your iPad synced before 8AM the day of IDT.

You should not copy and paste your prep notes from one IDT to another except to help with basic information.

You want to capture what you completed with patient in the week between patient being covered in IDT as well as what your plan is for the next two weeks.

Always try to capture any noticeable decline that has been witnessed or shared from facility staff or family.

Select patient on your ipad. (If patient is “greyed” out you need to touch the pin, sync, to pin to your ipad. )

Sync

Go to upper left (click on the three lines )

Select Communication Notes

Select Prep Notes

Enter Discipline

Enter note below in the format of:EXAMPLE: MSW to see patient 1-2x month, patient is less talkative with visits, only able to answer yes/no questions at this time instead of speaking in full sentences. Noted meal tray in room untouched. (You want to note the decline over the past two weeks) Note the plan for the next two weeks.

IDT PREP NOTES

PREP NOTE FORMAT EXAMPLE

For all prep notes following the initial assessment please utilize this format.

Jane Suncrest /3-18-2020 IDT Prep Note :

PATIENT OBSERVATIONS: Patient declined most recent visit offered in the month of March. Patient has agreed to allow this writer to visit on 3-20-2020. Formerly, the patient has routinely been observed to be sitting in her recliner resting. She is often leaning forward and/or to the side with the majority of weight beared on her knees or the armrest. Patient displays and reports to have fatigue with chronic pain in her back. Patient will report that her sleep at night is inconsistent due to restlessness. Patient requires to take several rest breaks during conversation as a result to shortness of breath.

PSYCHOSOCIAL: Patient remains alert and oriented to person, place, and time. She participates in meaningful conversation. She confirms that her desire to die in her home. The patient speaks of death and verbalized that she is not afraid. She enjoys participating in conversation that is reflective of both long and short term history.

CAREGIVER: Patient has appointed her husband, John, as Durable Power of Attorney for Healthcare Decisions. John is also the patient’s primary caregiver. He will indicate that he too has the desire to care for the patient in the home until death, but can become frustrated when care is inconvenient or taxing.

COLLABORATION WITH IDT AND FACILITY: Social worker communicates with Hospice RN following visits regarding patient, caregivers, or DPOHC’s expressed needs.

PATIENT GOALS: To remain as comfortable as possible from a physical, emotional, and spiritual standpoint. Patient desires to remain in her home until death.

PATIENT CARE PLAN INTERVENTIONS: Social worker provides psychosocial/emotional support to the patient in the form of companionship, assessment of coping skills, and facilitation of life review. Social worker will remain available for education regarding the end of life process for the patient and family.

Susan Suncrest, LBSW

Document,

Document,

Document……….

RECERTIFICATIONSRecert Periods- 1st Benefit Period 90 days,

2nd Benefit Period- 90 Days,

Then 60 days periods (unlimited 60

day periods.)

Checklist · Bereavement Follow Up Visit

Dashboard:

VISIT INFORMATION:

If visit not already scheduled: Tap on Add Visit on the Service calendar (the discipline inserted in your ‘set as

primary’ field will determine the type of notes you will be able to choose) Select the patient Select the visit type ‘initial’ Tap Done Synchronize Select the visit on the Home page Add the Bereavement After Death visit note

Visit Note (Dark Gray Tab)

ADMINISTRATIVE SCREEN:

Enter Time in, Mileage, Travel Time, and Supplies

Add Service Code

Swipe down and tap on the patient name to access the Medical Record

Medical Chart (Light Gray Tab)

CONTACTS:

Review/Add Personal contacts Designate Bereavement Contacts as appropriate (if receiving Bereavement Mailings

enter Risk Code, mailing address and click ‘Yes’ for receiving mailings) Add Organizations as appropriate (funeral home etc.)

Visit Note (Dark Gray Tab)

CARE PLAN DOCUMENTATION:

Document against the Care Plan

ASSESSMENT:

Document all categories within the assessment – when complete all items will have a

check mark

▪ Skip the Flow Sheets and ESAS areas

NARRATIVE:

Enter Narrative as appropriate

REVIEW AND SUBMIT:

Enter Time Out

Close Visit Note

Medical Chart (Light Gray Tab)

COMMUNICATION NOTE:

Add communication notes as appropriate

o Prep note, Interdisciplinary Referral notes as needed

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