Hospital Psychosocial Assessment & Discharge Planning Note

(Use person-first, non-stigmatizing language. Attribute key facts to sources such as patient, family/caregivers by name/relationship, chart review, and interdisciplinary team. Use direct quotes sparingly for pivotal goals, refusals, and safety-relevant statements. For required or high-risk domains with missing data, include explicit placeholders such as "Not assessed" or "Unable to assess due to [reason]" rather than omitting.)

Note Type: [Initial Assessment / Update / Discharge-Day Update]

Date/Time of Encounter: [Date and time]

Author/Credentials: [Name, credentials]

Encounter Modality: [bedside / phone / video / chart review only]

Reason for Consultation: [Reason for consultation] (e.g., routine psychosocial assessment for discharge planning, or specific consult such as housing instability, caregiver concerns, placement needs, safety concerns, insurance barriers)

Clinical Context

(List 2–5 bullets with only the medical context necessary to frame discharge planning. Do not restate full medical history.)

• [Admitting diagnosis and brief hospital course relevant to discharge]
• [Key active medical/psychiatric issues affecting disposition or services]
• [Current unit/level of care if relevant]
• [Anticipated discharge timeframe if known]

Information Sources

• Patient interview: [yes / no] (If no, state reason: medically unstable, cognitive status, declined, language barrier, other)
• Family/caregiver interviews: [Names, relationships, and method of contact]
• Collateral contacts: [Agencies/contacts and roles] (e.g., APS/CPS, shelter, facility liaisons, insurers, benefits programs)
• Interdisciplinary inputs reviewed: [PT / OT / Nursing / Physician / Psychiatry / Case Management]
• Interpreter use: [none / in-person / video / phone] (If family interpreted, note whether professional interpretation was offered)
• Communication considerations: [Hearing / Vision / Cognitive / Health literacy / Language] (Only include when relevant to discharge planning)

Patient Goals & Discharge Preferences

[Narrative of the patient's stated goals for discharge destination and supports, including non-negotiables and preferences such as location, proximity to family, cultural needs, pets, mobility constraints. Note willingness to accept services such as home health, rehabilitation, or equipment.] (Use direct quotes sparingly for pivotal statements; clearly attribute to patient or named family/caregiver.)

Psychosocial Assessment

(Use bullets for factual inventories. Use brief narrative paragraphs for synthesis and clinical relevance to discharge.)

Living Situation

• Housing status/type: [stable / temporary / unhoused / institutional / unknown]
• Location and accessibility: [stairs / elevator / entry barriers / bathroom setup]
• Household composition: [Household members, relationships, pets]
• Home safety concerns: [none / noted concerns / not assessed] (Include only if assessed or relevant)

Supports & Caregiver Capacity

• Primary supports: [Names, relationships]
• Availability: [hours/days, distance, reliability]
• Willingness/capability for care tasks: [willing / unwilling / limited / unknown] (Specify tasks such as transfers, medication management)
• Training needs: [Required caregiver training and coordination with Nursing/PT/OT]
• Backup plan: [Alternative caregiver/agency plan if primary is unavailable]

[Brief synthesis on whether supports are adequate for the proposed discharge plan, noting risks and mitigation steps.]

Functional Status

• Baseline ADLs/IADLs: [independent / needs assistance / dependent]
• Current ADLs/IADLs in hospital: [independent / needs assistance / dependent] (Defer detailed scoring to PT/OT when available)
• Equipment at baseline: [none / cane / walker / wheelchair / commode / other]
• Anticipated care tasks post-discharge: [transfers, mobility, bathing, toileting, wound care, medications, appointments]

Social Determinants & Barriers

(Document relevant SDOH domains affecting discharge. For each, note status, impact on discharge, and mitigation actions taken or planned.)

• [SDOH domain]: [Status]; [Impact on discharge]; [Mitigation actions/plans]

(Common domains: housing stability, food access, transportation, financial/medication affordability, insurance limitations, social isolation/caregiver strain, access to primary care/pharmacy)

Safety Concerns (if applicable)

(Include only when screening was performed, when patient is vulnerable, or when concerning findings emerged.)

• Screening status: [completed / not completed] (If not completed, state reason)
• Patient statements: [Direct quotes or "Not disclosed"]
• Observations: [Relevant observations indicating risk or vulnerability]
• Immediate actions: [Mandated reporting, APS/CPS referral, security, safety planning]
• Discharge implications: [How safety concerns inform disposition and follow-up]

Decision-Making & Advance Care Planning (if applicable)

• Identified decision-maker/surrogate: [Name, relationship]; Source: [advance directive / POLST / EMR / verbal report]
• Guardianship status: [Status or N/A]
• Advance directive status: [present / absent / unknown]
• Capacity concerns: [Observations only]; Notified: [Provider/team notified per policy]

Discharge Planning Evaluation

Working Disposition

• Proposed destination: [home alone / home with supports / home with services / SNF / IRF / LTACH / medical respite / shelter / other]
• Anticipated discharge date: [Date or timeframe]
• Pre-discharge requirements: [What must occur before discharge]

Options Considered

(For each post-acute option considered, note clinical appropriateness, patient preference, resource feasibility, and barriers with mitigation.)

• [Option]: [Clinically appropriate / not appropriate]; Patient preference: [accepted / declined / undecided]; Feasibility: [insurance, bed availability, geography]; Barriers/mitigation: [Brief notes]

Patient Choice Documentation

[Document that provider options were presented and discussed when post-acute services are indicated. Note the patient's/family's stated choice and rationale, or reason for deferral. If quality or resource-use data were reviewed, note in general terms.]

Access & Non-Clinical Services

• Transportation: [mode, payer, timing, contingency for discharge day and follow-up]
• Pharmacy/medication access: [barriers, bedside delivery, prior authorization, cost coverage]
• Home access issues: [keys, utilities, phone, food availability]
• Community services needed: [meals, benefits navigation, housing supports]

Interventions Today

• [Calls placed: names/agencies, purpose, outcomes]
• [Referrals submitted: type, date/time, status]
• [Forms/applications completed or initiated: type, status]
• [Family/caregiver meetings: attendees, outcomes]
• [Team coordination with CM/PT/OT/Nursing/Physicians: key decisions]
• [Communication with receiving facilities/agencies: contact, acceptance status, next steps]

Assessment Summary

[Narrative synthesis (4–8 sentences) summarizing key psychosocial factors enabling or complicating discharge, primary barriers and risks, rationale for the recommended disposition, risk mitigation plan, and remaining uncertainties.]

Discharge Plan & Follow-Up

(Problem-oriented list with action steps, responsible party, target dates, and status. Document refusals with risks/benefits reviewed and resources provided.)

• [Barrier/Need]: [Action steps]; Responsible: [Party]; Target: [Date]; Status: [planned / in progress / completed]
• Caregiver plan: [who will do what, training needed, backup plan]
• Transportation: [ride type, payer, pickup time, contingency]
• Referrals: [agency, status, expected start date]
• SDOH needs: [benefits, housing, food, utilities with referral status]
• Safety plan (if applicable): [safe contact method, resources provided, protective steps]
• Post-discharge follow-up: [SW follow-up call timing, PCP appointment timing, other appointments]

Handoff & Continuity (if applicable)

(Include when discharge is not imminent, case transfers to another SW, or outpatient follow-up is arranged.)

• Pending tasks: [Task and owner]
• Recommended next contacts: [Names/agencies, target dates]
• Time-sensitive deadlines: [facility acceptance windows, benefit document deadlines]
• Receiving SW/outpatient contact: [Name, agency, contact info]

Signature: [Name, credentials]

Role/Service: [Role/Service]

Contact: [Phone / pager / secure email]