Psychosocial Assessment (Hospice Social Work)

Visit Date/Time: [Date and time of visit]

Setting: [home / facility name / inpatient unit] (Specify unit/room if relevant.)

Visit Modality: [in-person / telephone / video / collateral-only]

Persons Present: [patient, family members by name and relationship, facility staff roles, interpreter] (Note if patient was not present.)

Information Source(s) and Reliability: [patient / caregiver / facility staff / chart / other collateral] (Comment on reliability and consistency across sources.)

Language and Communication Needs: [preferred language] | [interpreter used: yes/no and type] | [communication barriers or accommodations]

Consent Boundaries: [patient permissions for information sharing, topics declined] (Include only if patient expressed specific preferences; omit if not applicable.)

Reason for Assessment

[Assessment trigger and patient/family priorities] (1–3 sentences identifying trigger such as [new admission / IDG request / caregiver concern / safety event / transition of setting / escalating distress / new caregiver]. Include patient/family-stated priorities if available.)

Patient Context and Living Situation

[Current living arrangement and care setting] (Home type or facility, who lives with patient, level of caregiver/facility support, expected hospice visit frequency as understood by family.)

[Functional and cognitive factors relevant to psychosocial planning] (Mobility, ADL/IADL support needs, cognitive status, communication abilities.)

[Environmental factors affecting care delivery] (Access issues, safety hazards, equipment space constraints, privacy considerations.)

Family System and Support Network

[Family as defined by the patient] (Include family of choice; identify key relationships.)

[Primary caregiver and responsibilities] (Medications, symptom monitoring, personal care, finances, transportation, household tasks; availability and competing responsibilities.)

[Backup caregivers and out-of-area supports] (Names/relationships, availability, preferred roles.)

[Communication patterns and decision-making style] ([unified / shared / spokesperson-led / conflictual]; how decisions are typically made.)

[Caregiver willingness and capacity] (Physical limitations, health literacy, understanding of hospice scope, readiness to learn.)

[Bereavement risk indicators] (Prior losses, complicated grief risk factors, limited supports, high conflict, dependent relationship, trauma history.) (Omit if none identified.)

Coping and Psychosocial-Spiritual Status

[Patient coping and adjustment] (Acceptance, hopefulness, avoidance, denial, values and meaning. Include brief direct quotes when they meaningfully capture values or goals.)

[Caregiver coping and stress level] (Observed and reported mood/anxiety; signs of burnout.)

[Serious emotional distress] ([none identified / present]: hopelessness, panic, severe caregiver burnout, uncontrolled anger.) (Document objective observations if present.)

[Spiritual or existential concerns] (Meaning, hope, guilt, fear of dying; chaplain coordination if indicated.)

[Strengths and protective factors] (Faith community, supportive relationships, effective coping strategies, resilience, prior problem-solving successes.)

Cultural and Health Equity Considerations

[Cultural factors influencing care] (Decision-making norms, disclosure preferences, symptom expression, end-of-life rituals.)

[Language, literacy, and access considerations] (Health literacy, preferred education formats, interpreter needs, transportation, finances, caregiving coverage.)

Practical Resources and Barriers

[Financial/insurance stressors affecting care] (Medication costs, equipment, income loss, housing insecurity.)

[Current benefits/resources and referrals] (Medicaid, VA, community programs, respite options; referrals placed and status.) (Do not guarantee eligibility or approval.)

[Care logistics] (Equipment constraints, caregiving schedule feasibility, transportation, backup plans.)

Safety Screening

• Environmental safety: [Falls hazards, unsafe medication storage, wandering risk, other hazards] [no concerns / concerns identified]
• Neglect concerns: [Unmet basic needs, missed care, medication mismanagement] [no concerns / concerns identified]
• Abuse or exploitation concerns: [Physical, emotional, financial] [no concerns / concerns identified]

(If concerns identified: Document objective observations and specific behaviors/events. Avoid labels. Do not document details that could increase risk if record is viewed by alleged perpetrator.)

[Mitigation steps taken] (Education, safety planning, equipment adjustments, removal of hazards.)

[Team notification and mandatory reporting] (What was reported, to whom, when, reference number if applicable.) (Include only if reporting occurred.)

Decision-Making and Advance Care Planning

[Patient decisional capacity as observed] (Ability to understand, appreciate, reason, and communicate choices.)

[Surrogate decision-maker] (Legally designated healthcare proxy/DPOA vs default surrogate; how verified; contact information.) (Do not infer from presence alone.)

[ACP document status] (Advance directive, healthcare proxy/DPOA, POLST/MOLST, code status; whether documents are on file.)

[Goals and values discussion] (What matters most, acceptable/unacceptable outcomes, preferred setting of care/death.)

[Education provided and next steps] (ACP education, document completion plan, timeframes.)

Assessment Synthesis

[Summary of key psychosocial drivers of risk and resilience] (Describe how these factors affect symptom management, setting stability, adherence, and crisis risk.)

Prioritized psychosocial needs:

• [Priority need 1 - highest risk/urgency]
• [Priority need 2]
• [Priority need 3]

(Add or remove priority items as appropriate.)

Psychosocial acuity: [low / moderate / high] (Include defining factors.) (Omit if agency does not use acuity rating.)

Interventions Provided

• [Supportive counseling] (Focus and approach used.)
• [Caregiver education] (Topics covered; understanding demonstrated.)
• [Resource coordination/referrals] (Agency/program, purpose, status.)
• [Advocacy and systems navigation] (Insurance, benefits, facility coordination.)
• [Family meeting facilitation] (Participants, goals, outcomes.)
• [Safety interventions] (Actions taken.)

(Include only interventions that were provided.)

Patient/caregiver response: [understanding / agreement / decreased distress / declined / other]

Psychosocial Plan and Follow-Up

(Use problem-oriented format for each identified need.)

• Problem/Need: [Description]

  Goal: [Measurable or observable target]

  Interventions: [Planned interventions] | Responsible: [SW / RN / Chaplain / Facility / Caregiver]

  Timeframe: [Target date or interval] | Contingency: [Actions if worsens]

(Repeat structure for each problem/need.)

Social Work Follow-Up: [Next visit timing and PRN parameters]

ACP Next Steps: [Documents to complete, who will assist, timeframe] (Omit if ACP complete.)

Caregiver Support Plan: [Respite exploration, education plan, family involvement]

Safety Follow-Up: [Monitoring plan and actions] (Include only if safety concerns identified.)

Bereavement Program Flag: [yes / no] (Include risk indicators if flagged.)

Care Coordination

[IDG communication] (Key risks, plans, and requests communicated; to whom.)

[Facility/provider coordination] (Names/roles, topics, agreements.) (Include only if applicable.)

[Referrals placed] (Bereavement program, chaplain, community agencies; status.)

(If clinically necessary information is missing—primary caregiver identity, decision-maker, safety-relevant details—document why missing, what was attempted, and plan with timeframe to obtain. If a core domain was not assessed due to patient fatigue, crisis, or absence, explicitly state it was not assessed and why. For high-stakes documentation—abuse/neglect, suicidal ideation, capacity concerns, surrogate identity, mandatory reports—document objective details and actions taken without inference.)