Psychosocial Assessment Note (Palliative Care Social Work)

Date/Time: [Date and time of encounter]

Social Worker: [Name, credentials, team/service]

Setting: [inpatient / outpatient / home]

Encounter Type: [in person / video / phone]

Language: [Preferred language]; [interpreter used: yes/no]; [Interpreter name/ID if used]

Participants: [Who was present: patient, family members by relationship, caregivers, other staff]

Consent for Family/Caregiver Participation: [Authorization source and scope of information sharing]

Information Sources: [Direct patient interview / collateral: chart review / collateral: nursing report / collateral: family/caregiver call] (Label all collateral sources.)

Referral Context

Consult requested by: [Referring service or person]

Reason for consult: [Problem-focused language, e.g., coping support, caregiver stress, housing/financial instability, transportation barriers, advance care planning support, family conflict, resource coordination]

Priority concerns: [List 1–5 concerns in descending urgency]

Deferred concerns: [Concerns deferred due to time constraints and reason] (Include only if applicable.)

Psychosocial Narrative

[One-sentence synopsis anchoring diagnosis/trajectory context, living situation, and why support is needed now]

[Patient's understanding of illness and meaning to them; salient emotional themes such as fear, uncertainty, hope, anger] (Use brief direct quotes for values or fears guiding decisions.)

[Current coping strategies and strengths: routines, faith/spiritual supports, social network, engaged caregiver, prior resilience] (For brief follow-up visits focused on a single issue, abbreviate or omit this section.)

Psychosocial Assessment

(Include only domains assessed and relevant to the encounter. For high-stakes areas—safety, discharge feasibility, caregiver availability—if not assessed, document "Not assessed" with reason and plan to obtain.)

Support System and Relationships

[Patient-defined family/household composition including family of choice; key supports and relationship quality; decision-making patterns within the family; social isolation risk; recent losses]

Caregiving Situation

[Primary caregiver identity, availability, willingness, and capacity; care tasks performed; competing demands; stress indicators; backup/respite options; screening tool name/score/interpretation if used] (If no reliable caregiver identified, state explicitly and note implications for safety or discharge.)

Living Situation and Safety

[Housing type and stability; who lives with patient; home safety concerns including falls risk, accessibility, stairs, DME/modification needs] (Required when plan depends on home feasibility.)

Practical Needs

[Functional status as it relates to caregiving burden and resource needs; transportation barriers; food access/nutrition insecurity; medication access barriers; employment/role disruptions]

Financial and Insurance Barriers

[Insurance type and relevant coverage gaps; financial stress markers; benefits in place or under consideration; concrete next steps] (Focus on functional impact and actions.)

Cultural and Communication Preferences

[Preferred name/pronouns if offered; cultural factors affecting illness understanding, support preferences, or decision-making; religious/spiritual supports relevant to coping; prior healthcare experiences affecting engagement if raised]

Mental Health and Distress

[Pertinent mental health history and current treatment; current symptoms relevant to care; substance use only as it affects coping, safety, or care plan; standardized screener name/score/interpretation and resulting action if used]

Safety Risk Assessment

(Include when any concern arises or screening suggests risk.)

[Suicidal ideation/self-harm: presence or absence, acuity, protective factors; abuse/neglect/exploitation concerns; findings; immediate actions taken; notifications made; follow-up plan] (If assessment cannot be completed, document reason and mitigation steps.)

Illness Understanding and Decision-Making

[Patient's stated understanding of illness and likely course; readiness for information and preferred communication style; decision-making approach; identified surrogate decision-maker and documentation status]

Advance Care Planning

(Include when ACP was addressed or when gaps materially affect care; omit if not relevant to this visit.)

• Document Status: [Healthcare proxy/DPOA-HC status; living will/advance directive status; POLST/MOLST status; code status if addressed, including patient understanding and team communication]
• Values and Goals: [Outcomes that matter most to patient; unacceptable states in patient's words; family alignment or misalignment] (Do not infer goals from diagnosis—document explicit patient statements.)
• ACP Interventions: [Education provided; facilitation actions; documentation logistics addressed]

Conflict Mediation

(Include only when family or treatment-related conflict is present.)

Triggering issue: [Treatment decisions / caregiving roles / communication breakdown / other]

Parties and perspectives: [Attribution-based summaries, e.g., "Patient reports...", "Daughter states..."]

Mediation actions: [De-escalation strategies; structured meetings held or planned]

Outcomes: [Areas of agreement; unresolved issues]

Recommendations: [Ethics consult, chaplaincy, family meeting with clinician, other] (Use fact-based, nonjudgmental language.)

Social Work Assessment

[Clinical formulation synthesizing key stressors and barriers, strengths and protective factors, clinical impression of coping, and overall psychosocial risk level with supporting evidence]

Priority psychosocial problems: [Problem list aligned with patient goals]

Discharge feasibility/caregiver sustainability: [Risks and considerations] (Include if relevant.)

Interventions

• [Supportive counseling/psychoeducation provided; topic and patient/caregiver response]
• [Care coordination contacts: who, method, and outcome]
• [Referrals placed: agency/program, eligibility discussed, patient consent obtained]
• [Applications initiated: program, status, required documents]
• [Advocacy actions: issue, stakeholder, result]
• [Safety interventions: steps taken, notifications, immediate plan]

Plan

(Organize by problem when multiple issues exist.)

• Problem: [Problem name]

  • Goal: [Measurable objective]
  • Actions/Referrals: [Agency/program, contact information, eligibility notes]
  • Responsible party: [SW / patient / caregiver / team member]
  • Timeframe: [Target completion]
  • Consent/ROI: [Status and scope]
• Next SW contact: [Timeframe and modality; triggers for earlier outreach]

Team Communication

Team members updated: [Names/roles and communication modality]

Key recommendations communicated: [Brief summary, e.g., need for family meeting, high caregiver strain, discharge barriers]

Items escalated urgently: [Safety risk, abuse concern, critical discharge barrier] (Include only if applicable.)