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SOCIAL WORK DEPARTMENT
GUIDELINES FOR PSYCHOSOCIAL ASSESSMENT
These are general guidelines for all areas and divisions of the Department. It is expected that each
division will have specific guidelines, which meet the clinical and third-party needs of that division.
These guidelines are not meant to specify the format that an assessment is expected to take, merely
the content.
Issues of frequency of recording and frequency of assessment/reassessment will be decided by each
division, in accordance with good practice and with payor requirements.
In ambulatory settings, the initial assessment should be completed by the second meeting, with
documentation occurring after the initial meeting that reflects that the assessment is in process.
Progress notes should be written after each session and treatment summary updates should be
written every three to six months, depending on the payor requirements. When treatment has been
concluded, there will be a corresponding treatment summary.
Within inpatient settings, initial assessments should be completed and documented in the record
within one business day of referral. If patient is unable to be assessed within one day of referral,
social work should document acknowledgement of referral and plan for follow up. Because
assessment is an ongoing process, reassessment and changes are noted as new and/or collateral
information is obtained. Documentation of the ongoing work and reassessment will be contained in
the progress notes, with a standard of a minimum of one note per week on any open case.
It is understood that in cases of crisis intervention it will not always be possible, either for reasons
of time or clinical appropriateness to gather all information, particularly that which relates to
history. However, when feasible, this will be the standard.
I. Identifying Information
A.
B.
C.
D.
E.
F.
Reason from referral
Referral source
Age
Ethnicity, religion
Marital status
Presenting problem and duration
II. Previous level of functioning (i.e., prior to hospitalization and/or social work assessment.)
A.
B.
How medical status impacts level of functioning – ADL status
Work, school, etc.
III. Support Systems
A.
B.
Family constellation and/or significant others
Community supports (individuals and agencies)
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IV. Financial Status
A.
Entitlements an/or eligibility
V. Relevant past history
VI. Assessment
A.
B.
C.
VII.
A.
B.
Mental status
Problems/needs as perceived by patient and worker
How these problems are understood/accounted for based on information obtained
Plan
Follow-up by Beth Israel Deaconess Medical Center social work
Referrals to other providers/agencies
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