Hospice social work visit notes made easy

Welcome to the first of a pair of articles about the basics of documenting hospice social work.

In a future post, we’ll tackle how to get your visit notes done quickly. Today we’ll look at how to get the visit note done well.

Templates and checklists are not your friends

Templates and checklists are going to be a part of your life, because they are how hospice agencies ensure some uniformity and completion in documentation. But they can be misleading, because just because you filled out the form according to the form’s specifications doesn’t mean your documentation is complete. The other issue with checklists or templates is that they take up space. I’ve seen forms, both paper and electronic, that have lots of boxes to check and provide only a tiny bit of space for the human assessing to express any thoughts.

If I had to choose between a form of checklists filled out by anyone versus a single narrative written by a knowledgeable social worker, I’d choose the latter every time.

Document the 5 Ws

As a social worker, and you know what information needs to be provided in your note. You need to include the 5 Ws: the who, what, when, where and why. The what needs to include information about any dimension of the patient’s experience that has been of focus prior to this visit, or a change that’s been indicated during this visit. They why can be the purpose of the visit, and whether it’s routine or PRN.

The 5 Ws can function just like the lead in a news story (and here we get some inspiration from my other career as an Army journalist). It provides a bottom line up front. After that you can explain whatever else happened or was said that’s crucial to the patient’s situation.

Document anything that relates to ongoing concerns

You do not need to quote or paraphrase the entire interaction you have with your patient, but write down anything that shows how an ongoing issue is progressing. If one of your goals for this patient is to educate regarding a DNR, and today the patient said, “Yes, I see…But I don’t think I’m ready,” than paraphrase that.

Document the standard status stuff

During routine visits, you most likely ask several questions that relate to routine topics, such as comfort, alertness and orientation, sleep and appetite. Document all of these, both to help keep your team informed on how the patient is doing, and also to have potential evidence of decline to support re-certification. If there is discomfort or pain, relay this to the patient’s nurse case manager and document that communication.

Document what patients say and do

Leave out your own judgment and perspectives, and state what patients and family members say and do. If you had a great visit, that’s great. But don’t write that. If the patient says it was a great visit, put that instead: “Patient states she enjoyed our visit.” Don’t write that the patient’s daughter understands the role of hospice. How would you know? But if she is able to demonstrate understanding, you can write, “patient’s dtr expressed understanding of hospice role.”

You can include analysis, but be clear that it is your inference and what you are basing it on. For example: “Pt repeated looked downward with unhappy expression when family-related topics came up, indicating some unresolved emotions relating to his family.”

There you have it.

Now that you have the basics, here are 5 tricks to getting your notes done in less time, so you have more time for things you enjoy more… there’s a lot I enjoy more than documenting.

Here’s OUR mission

Let’s raise the bar in hospice by giving hospice social workers tools that make them more confident in their expertise from the get-go. Please share this article or this site so that more hospice social workers can shine in their profession, making all of us look good!

Click here to share to Facebook, here for Linkedin, here for Twitter, and here for GooglePlus!

---

Michael Giles is a hospice social worker and psychotherapist who works in Austin and Cedar Park, Texas.

Also by Michael: How to be a good dad (when you’re feeling tense, anxious, irritable, etc.)