Social Work Assessment

Name of Responsible Person: Relationship: Phone: PT/CL Name: Date:

Address:

Person to Contact in Emergency: Relationship: Phone: City, State, Zip:

Phone: D.O.B Sex M F

Prior Medical Social Work Service Referral Source/Date

Frequency/Duration of Visit

Rehabilitation Potential Physician Phone

Diagnosis Date of Onset AGENCY/SNF: Dates of Stay:

Primary

Secondary AGENCY/SNF: Dates of Stay:

SPECIFIC INFORMATION DESIRED ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

I. PERSONAL, PSYCHOSOCIAL AND FAMILY FUNCTIONING AND FINANCIAL INFORMATION: A. HOUSEHOLD MEMBERS SIGNIFICANT OTHERS COMMENTS (names and relationships) (names and relationships) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ B. BEHAVIOR INDICATORS/PSYCHOSOCIAL FUNCTIONING. Key PT = Patient PCP = Primary Care Person

GOOD FAIR POOR COMMENTS PT PCP PT PCP PT PCP

Functional Ability

Memory

Comprehension

Judgement/Decision Making

Communciation Ability

Knowledge of Health Problems

Motivation to Resolve Needs

Compliance with Treatment

Ability to Accept Help

C. Significant psycho/social/emotional factors/needs for counseling: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Refer to Case Manager: _____________________ Psych Nurse: ____________________ MHMR:____________________ Other:__________________

Client/Designee: I certify that the Matrix Home Cae Employee listed on this time slip worked the times indicated and the owrk was performed in a satisfavory manner. I agree to the times regarding this time slip.

Employee Signature: _________________________________

Patient/Client Signature: ______________________________

PT/CL NAME: _____________________________________

ADDRESS: _______________________________________

CITY, STATE, ZIP: __________________________________

VISIT DATE: ____________________________________________

TIME IN:__________________ TIME OUT: ______________

10/09/12 Medical Social Work Assessment Page 1 of 2

MATRIX HOME CARE MEDICAL SOCIAL WORK ASSESSMENT

MATRIX HOME CARE MEDICAL SOCIAL WORK ASSESSMENT Patient/Client Name: _______________________________________________ Date: _____________________________

II. ASSESMENT SUMMARY:

III. LONG-TERM CARE PLANNING: ______ Access community resourse utiliztion on ongoing basis ______ Provide information, referral consultation & collateral contacts as needed ______ Counsel/teach re: appropriate community resourse utilization ______ Instruct pt/family to call Care Team if assistance needed after discharge

IV. Problem Areas/Reasons: Indentify factors which are impeding patients ability to achieve maximal health potential/compliance with treatment plan.

HOUSING: Adequate YES NO Due to: Crowing Santitation Structural deficiency Neighborhood Dysfunctional utilities

Other: _____________________

EQUIPMENT/SUPPLIES/INFORMATION: Adequate YES NO Due to: Knowledge deficit Income deficit

Other: _____________________

INCOME: Adequate YES NO Due to: No income resource Disproportionate living or medical expenses Poor financial planning/ decision making

Other: _____________________

SAFETY: Adequate YES NO Due to: Lack of supervision Abuse/neglect Poor judgement Environment Alcohol/substance abuse Prome to falls or medical emergencies

Other: _____________________

TRANSPORATION: Adequate YES NO Due to: Unable to drive Unable to ride in car Driver no available Can’t afford Inaccessibility

Other: _____________________

PERSONAL CARE/HOUSEKEEPING: Adequate YES NO Due to: Lives alone Elderly/ill PCP Extreme dependency of pt. Employed PCP Refuses to accept help Cannot afford to hire

Other: _____________________

FOOD MEALS: Adequate YES NO Due to: Pt/PCP unable to prepare meals Inadequate income Inability to shop for groceries

Other: _____________________

OTHER: __________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________

Comments: ________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature: ________________________________________________________ Date: ___________________________

10/09/12 Medical Social Work Assessment Page 2 of 2