Documentation Documentation A SSD must remember to document very thoroughly. The responsibilities and challenges of a SSD keep growing in direct proportion to the increased needs of the people they serve. The type of staff performance once expected only in hospitals has now worked its way into standards of nursing homes, assisted living and adult day centers. Federal regulations and voluntary accreditation standards have changed the face of long term care forever changes have added to the work responsibilities for all staff members. The beauty of the change is that the focus is on the individual and how we as a team can assist each one in meeting goals and projecting outcome.
The work that you put your spirit and soul into will not only make an impact on the people we serve living today in long term care settings, but create increasingly higher standards for the generations in the future.
Social Services Documentation
We will discuss the documentation required for each resident.
1. Initial Assessment Form
Assessment of the newly admitted resident. Identifies psychosocial needs, concrete
needs, interests, strengths and lifestyle. Leads to development of the resident care plan.
Completed prior to the MDS. (Review admissions previously discussed)2. Resident Assessment Instrument (RAI) = MDS+RAPs
Comprehensive interdisciplinary assessment of the newly admitted resident by day 14 of
admission. Social services professional is usually responsible for completion of Sections
AC, E, F and Q and if triggered, the related RAPs and the information on the RAP
Summary form. Quarterly MDS completed every 90 days thereafter and a full MDS
annually and on significant change in condition. Additional MDSs may be required for
billing purposes.
- Click here to see the MDS forms and review your portion to complete. MDS Example
- If you haven't already, print off the following supplements:
3. Care Plan
Started on admission to address immediate needs. Comprehensive interdisciplinary care
plan based on assessment and the RAI completed within 21 days of admission. Identifies
mood, behavior or psychosocial problems that need resolution or management. Sets goals
to measure effectiveness of interventions.
- These links may be helpful for learning more and compiling a plan of care:
4. Social Services Log
Ongoing documentation of services and counseling provided to the resident. May be
documented in a separate log or in the resident’s health record. Follow up note is required
to document resolution or outcome of the interventions.5. Quarterly Progress Note
Completed with the MDS review. Documents overall progress for the previous quarter.
Assesses the resident for any unmet needs. Addresses any changes in coding on the MDS
and the need to revise the care plan interventions in response to these changes. The
rationale for decision to revise or not revise the care plan is documented in the progress
note. (see example below)6. Change in Condition Progress Note
Completed with any changes in mood or behavior problems, including starting or
stopping use of a psychotropic drug or a physical restraint. Changes may be temporary,
due to an illness or changes in environment, or may be permanent. Progress note
addresses the need for a revised interventions and the care plan is updated. Permanent
changes due to a decline in physical, mental or psychosocial functioning are assessed by
the interdisciplinary team for the need for a new MDS.7. Discharge Plan and Progress Note
Started on admission to assess potential for discharge. A care plan is initiated for the resident with a
potential for discharge to a lesser level of care. Periodic progress notes track the progression of the
discharge planning. A final note must show that sufficient preparation and orientation have been provided
to assure a smooth transfer. The note summarizes the outcome of the plan and post discharge planning.
Resident/family training, resident counseling and post discharge referrals are documented.
Please click into the link below and review pages 31-36. A test will be given to you from this material. The Missouri Long-Term Care Ombudsman Program 2008 printed this material for the SSD. I would suggest you print a copy (if you haven't already) for future reference and for referral when taking the Unit test. Role of the Long Term Care Social Worker |
CARE PLAN
Care plan implementation involves an array of care management activities through which the care plan is put into effect. These activities may include providing information about available services, as well as educating clients and family members about how to access services or perform specific care activities themselves. It may also entail “service coordination,” which we define as the active involvement of a person or persons, such as clients, family members, or case managers, in arranging for or maintaining specific services.
Care plan implementation should be timely and cost-effective, with the goal of maximizing “client independence and choice while using the least intensive, least intrusive, most cost effective, and highest quality interventions.”
Information and education are also seen as important components of the process, since many consumers are not knowledgeable about the long-term care system and require specific instruction about how to maximize their access to and utilization of needed health and social services.
There is also recognition that implementation involves a variety of considerations, such as the services and goals identified in the care plan, funding limits and authority to purchase services, availability of local providers, and size of caseload.
It is widely recognized that not all clients need or want help with implementing their care plans. For example, they may not need information about services when the care plan is simply a replication of services already in place, or they may wish to coordinate services themselves or have family members who are capable and willing to do this.
On the other hand, some clients do not have the capacity or desire to implement their own care plans due to factors such as lack of family support or cognitive or physical impairment. Under these circumstances, assistance with implementation of care plans for these clients, including service coordination, may be desired by them or required to ensure safety.
You may go to “Labs” and play a game to test your knowledge on care plans.
Quarterly Progress Notes
Your responsibilities at the time of the quarterly update are to complete your section(s) on the MDS, review your prior progress note and review the existing care plan. In the case of a participant for whom behaviors are being monitored (with or without chemical intervention), you will need to review the audit record to assure that the MDS is filled out accurately.
This being completed, proceed with a quarterly note and necessary care plan revisions. The social services professional looks at different parts of the individual’s life. View your note as a summary of events; recap important occurrences in the quarter ad note any changes. Consider the following:
Reflect, where appropriate, the components of these elements of a participant’s record:
At the end of your note, it is advisable to address:
Example of Social Services Quarterly Progress Note:
01/12/2009
Lydia has been here for three months now and has worked very hard to make an adjustment to this environment. She came here from a loving home environment which could no longer support her, given the escalation in her personal care needs related to a compression fracture in her spine which compounds the existing circumstance related to a CVA she suffered in 1999.She very appropriately mourned the loss of her life as she had known it and SSD spent at least an hour a week with her reminiscing, dissecting the pros and cons of her present situation and gradually looking to a future (something she had verbalized to me after about six weeks into her admission that she had no sense of).
Lydia has rejected the idea of an antidepressant (which her physician had asked her to consider) feeling instead that she would rather “feel her emotions and deal with the issues now — not prolong the pain of separation.” There have been no observed indications of depression; Lydia has maintained as excellent appetite (gaining eight pounds over the quarter), sleeps well at night and says she has “nice dreams,” all counter indications of the usual signs and symptoms of depression. Her weight gain of eight pounds keeps her well within range of her normal body weight. (For further clarification, see dietary note.)
Lydia’s family, husband and one of two daughters who lives nearby, visit several times a week and have made her room homey, reflecting Lydia’s love of clowns and flowers. Lydia remains oriented, interested in her care and gradually has entered into an activity of her choosing.
Her placement remains appropriate at this level of care because of her dependence for care, her incontinence and her non-ambulatory status. Lydia’s advance directives are in the chart: she has expressed clear end-of-life wishes.
There are no apparent unmet concrete needs at present: she has new glasses, her dentures fit well and she is not hard of hearing.
SSD goal of visiting at least once a week to allow her to verbalize her feelings related to adjustment, with the additional intention of establishing a trusting relationship with at least one staff member, has been met thus far.
Because she is becoming more independent, emotionally and physically, within the facility, this goal will be revised to biweekly visitation for the next quarter.
S. Jones, SSD
6/08/01 SS Quarterly Progress Note
John is a very stable participant of three months duration in the facility. He has a diagnosis of Alzheimer’s disease (probable). His signs and symptoms are consistent with that as he is no longer able to identify himself, find his room or ask for what he needs. He is alert, however, and seems interested in his surroundings; he is a passive observer in most activities, responds to his name by making eye contact and appears to recognize his wife when she visits (daily at lunch) because he will smile and reach for her.John had been receiving Ativan for agitation and anxiety BID [two times a day]. He had been placed on this medication at home because of his behavior and the physician chose not to discontinue it upon admission, choosing instead to monitor and assess his behavior on the drug in this new setting.
At first John would become very restless, moving himself in his chair, reaching out to passersby and pulling at his clothes. This was noted especially in the evening, beginning at about 7 pm.
After several weeks of a trial with the medication, the staff was not noticing a major change in his behavior pattern and it was decided to attempt behavioral interventions to address John’s anxiety.
The goal of reducing his episodes of nightly anxiety was addressed by removing John from the main activity room and putting him in the room where there was quiet music being played and there were never more than five other participants in attendance. Staff would speak very calmly and softly and if John began to show any signs of motor restlessness, he would be calmed with a gentle and reassuring touch to his hand. These approaches have been successful to the extent
that the physician discontinued the Ativan at his last monthly visit.All concrete needs have been addressed at the present time: John has a new upper denture; he used to use glasses only for reading but no longer reads, thus is not in any way dependent on glasses. He has a hearing aid in his right ear, which he tends to remove. It can usually be found in his pocket. His family is aware of the risk of loss and feel that, at this point in his diagnosis, he wears the aid out of habit, not for “hearing.” The hearing aid is kept in the medication cart at night.
John’s care needs require the supervision necessary at this level of placement. He has a Durable Power of Attorney in the medical chart.SSD goal has been revised; John is visited at least monthly and during those visits, the goal is for him to respond in conversation by making eye contact when his name is used; he is also assessed for any personal care or clothing needs. If there are any, contact is made with his wife.
S. Jones, SSD
Some valuable advice
The best advice we can give you on actually getting these done is to stay organized and try not to let progress notes pile up. The requirements of the PPS (the facility doesn’t get paid unless the MDS is completed) make it likely that you will have a great deal more support from your facility management in getting your quarterly reports done than you did before the PPS was instituted. Doing them each week before the MDS review and participant care conference is the regulation. It is your responsibility to do your reports and provide other members of the interdisciplinary team with your unique perspective as they, too, comply with quarterly entry requirements.
Annual Review
Once a year you will participate in an annual review of each individual. The purpose of the annual review, unlike the quarterly review, is to completely reassess the individual. The team does a new MDS and any RAPs that are triggered. New, rather than revised, care plans are written.
Your participation is the same as it was in the initial assessment of the individual: supplying information for your section of the MDS, assisting with RAPs, reading through information from all the other disciplines and participation in the care plan conference.
Social services professionals are responsible for an annual update n the progress notes. This note is an overall summary that reflects change over the entire year. The annual date is determined by the date of the previous, full, validated MDS.
Sample Social Services Annual Progress Note
9/6/01 Social Services Annual Progress Note
Lydia has continued to make progress with an adjustment that started out with difficulties related to her mourning her previous life at home. She has been consistently verbal and able to express her feelings and has maintained an ongoing relationship with me, which has included at least biweekly “check-in” visits after the first quarter of weekly visits.Her health has remained stable with no further fractures or indications of new problems related to her original CVA. Her mood is optimistic and she has reached out to other alert individuals and they have formed a dining group that meets every day at lunch. This group is also the nucleus of the Resident Council and Lydia seems delighted to use her organizational skills as the elected secretary.
Her daughters offer love and support to her; her husband has himself suffered some major health problems during the year and his pattern of visiting four times per week has been reduced to two times per week. Lydia has been able to accept this new pattern without evidence of a setback in her mood, probably, she says, because she realizes that her husband, after so many years of focusing on her, must allow others to tend him now. She misses him but is always so happy to see him when he does visit that they spend their time catching up on events in their separate lives.
There have been no new medications needed; the MD’s progress notes regularly reflect Lydia’s stability and good humor.
SSD goal of biweekly visits has been revised to quarterly visits, which is a reflection of a well integrated individual.
S. Jones, SSD9/8/01 Social Services Annual Progress Note
John has had an expected decline due to his diagnosis of probable Alzheimer’s disease. He is no longer alert as evidenced by his keeping his eyes closed much of the time and he does not seem to respond to his wife any longer, not even opening his eyes when she speaks to him. He spends much of the day out of his room with the possibility that he will receive some form of stimulation.
John seems calm with no restlessness or aimless body movements noted. He is nonverbal and all of his needs must now be anticipated. Additionally, John has had a weight loss over the year representing about 10% of his body weight. He remains well within range of his ideal body weight but with his diagnosis a gradual weight loss is not inconsistent, even though he is fed all of his meals, consumes 75–90% of each and receives protein drinks between each meal and at bedtime.
John signed a Durable Power of Attorney for Health Care when he was well and his wife is able to make decisions regarding his care. She has asked that all possible comfort measures be provided, including relief of pain if necessary; he will remain with us, even if he develops further health care problems. She does not wish him transferred out to the acute care hospital.
John’s physician has noted the obvious decline during the past five monthly visits to him; there is no medication indicated.
The SSD goal has been revised to reflect these changes: during monthly visits with john, his concrete needs are assessed, he is monitored for any obvious change which should then be discussed with his wife.
S. Jones S.S.D.
Charting Tips
Keeping up with a participant’s needs (psychosocial and concrete) and changing conditions (health and behavior) is an ongoing challenge. It is only partly done if you know what the need/concern/problem is. To
complete the cycle you must reflect your knowledge and your plan in writing in the participant’s record.
Although this is not a regulation and will not even appear in any of the surveyors’ guidelines, it is a good social services practice to make an entry in the participant’s chart every week for at least the first two months. You can start it with each new participant and use it as a form of tracking his/her adjustment to the facility. Chart each week on some significant clue to the adjustment (or lack thereof) by indicating such things as knowledge of the facility: various rooms; recognition of faces, if not names, of staff and roommates; and familiarity with the approximate routine within the facility.
This charting will help you track the participant’s moods, find behavior patterns which might escalate into problems or begin to work toward appropriate discharge planning. Very importantly, you can determine if your current entry on the participant care plan is still a reflection of the participant’s need. Use a standard social services progress note form. A narrative style of documentation seems to work best for most social services entries.
If you find that weekly charting is not necessary because the participant’s overall independence and adjustment or, at the other extreme, very poor orientation and inability to respond to standard reality orientation, you can record this observation in the chart by making a note to that effect and change the frequency of the tracking.
Another way to document social services interventions is to keep a Social Services Log for each participant. This log is a record documenting services and counseling provided to the participant by the social services professional. The form could be a narrative or it might be similar to the Bedside Log used by the activity professional. Be sure to identify date, nature of service, participant’s response and the follow through that is required.
Duties and Responsibilities of the Social Service Designee
Provide social services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of the resident as discussed below:
1. Complete a psychosocial assessment and a social history within the required time after admission (14 days for federal regulations, 7 days for some states). This is to include the MDS and appropriate follow-up to that documentation.
2. Process all social services paperwork required by managed care systems in a timely manner.
3. Begin a discharge plan.
4. Enter on the resident care plan if there is an identified social services problem.
5. Always chart when a social services intervention has been indicated.
6. Complete a quarterly social services progress note.
7. Update the discharge plan annually for long term care residents and at least quarterly for residents who display a potential for discharge to a lesser level of care.
8. Reassess the social services entry on the resident care plan at least quarterly, updating problems, goals and approaches as appropriate.
9. Interpret psychosocial needs, strengths, goals and plans to appropriate staff.
10. Counsel residents and families during orientation and adjustment to the facility and during other times of crisis or trauma.
11. Participate with the interdisciplinary team in resident care conferences, presenting the psychosocial components of the resident’s needs and formulating a coordinated plan.
12. Identify changes in responses, behavior or personality, such as depression, anxiety, withdrawal or aggressiveness and discuss this with the interdisciplinary team; chart to this.
13. Maintain a file of community resources including community social and mental health agencies; appropriate referrals are made when necessary.
14. Maintain knowledge of current facility, state and federal regulations, policies and procedures as they apply to social services.
15. Facilitate and convene a Family Council as indicated by facility need.
16. Attend and participate in staff meetings, department head meetings, designated committee meetings and resident care conferences.
17. Participate in the facility inservice education program, especially as it applies to the psychosocial needs of the resident; this is coordinated with the Staff Development Director.
18. Other responsibilities as defined by the administrator.
Documentation below should be completed and on the chart
ON A DAILY BASIS PLEASE BE SURE TO COMPLETE:
COMPLETE ON A WEEKLY BASIS
COMPLETE MONTHLY
ONGOING
