Filed under: hospital, hospital social work, social work, social work practice | Tags: documentation, nurses
It’s been awhile since I’ve posted and I feel a little badly that my first post in so long is a bit of a rant…but whatever breaks the writer’s block, right?
So, as a social worker, why do we document? To protect against liability, a little CYA? To make sure you get paid (for those of you in private practice)? Because you’re ethically bound to do so? I think all of these answers are correct.
But, I feel like the main underlying reason we document is for communication. You are communicating to the insurance company about the progress your client is making. You are communicating with the rest of your agency about your client’s progress. If you’re in a setting like mine, it’s to communicate with the rest the interdisciplinary team (nurses, doctors, physical therapists, etc).
Today, I came close to losing it. Tomorrow, if I have one more person ask me if social work is involved with a patient, I may have to walk away and count to ten to avoid causing bodily injury to someone. We document in the chart in the hopes that that will be enough communication.
I’m not sure where this breakdown in communication is coming from, but it’s really getting to me. Grrrr…..
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UGH! The most enraging part of being a caseworker was when I would walk into court with a 10 page (mandated) report… and NO ONE WOULD READ IT!! /end rant.
Comment by socialwrkr_247 December 21, 2009 @ 9:59 pmOkay, I’m going to randomly assume that you put a note in the chart indicating that you were, indeed, involved with the patient. But did it stay in the chart??? We have found in our hospital that who ever clears out the charts will randomly take out social work notes so that you may have done a HUGE amount of work, but nobody knows it ‘cuz the notes are gone.
Of course, that is also assuming that they actually read the chart and didn’t just assume that you were not involved. 🙂
Comment by Carolyn Preston December 22, 2009 @ 8:06 amSo, Carolyn, we have electronic charting so there is no way for it to get lost, in the true sense of the word. Just today I had a physical therapist ask me which social worker was working with a particular patient. I said, “Well, that person isn’t on our census.” She says, “Darn, you guys always know how to get a hold of families.” I sat down with her and showed her exactly where to go in the electronic chart to get the contact info the nurses collect. I wanted to be like, “Hello, people! You don’t have to reinvent the wheel here or write an order to get another discipline involved! READ THE F#*&ING CHART!”
Comment by oregonamy1972 December 22, 2009 @ 7:40 pmHey Amy,
I am happy that as a macro social worker, I don’t have to deal with this anymore! Documenting can be very frustrating!
On a side note, I invite you to share your blog on My Social Work Network (http://www.mysocialworknetwork.com). It’s a free resource where social workers can create a professional profile, network, blog, search social work jobs, keep up to date on news, share resources, etc. We are looking for active social workers who like to blog and participate. You could also use the site as a tool to increase readership of your blog.
Feel free to visit the site and if you feel it adds value to the work we do, please help to spread the word.
Happy Blogging!
Comment by mysocialworknetwork December 31, 2009 @ 9:21 amMichelle C. Bussolotti, MSW