Hospice Medical Social Services Assessment

Standardized hospice medical social work assessment form to document psychosocial needs, family/caregiver support, community resources, and the initial intervention plan.

Assessment Context and Consent

• Assessment Date
• Assessment Type
• Assessment Location
• Consent to complete and document this psychosocial assessment
  Explain that this form may include PII and care-related information used for treatment, coordination, and audit trail purposes.
• What happens after I submit?
  The MSW and hospice interdisciplinary team will review this assessment, update the care plan, and coordinate resources or referrals as needed.

Patient and Family Profile

• Patient Name
• Medical Record Number or Internal Patient ID
  Use the internal identifier preferred by your organization; do not collect SSN.
• Primary Contact Relationship to Patient
• Household Members or Key Support Persons
  List only people relevant to care planning and support.

Psychosocial Status and Coping

• Current Emotional Status
• How effective is the patient/family coping at this time?
• Primary Psychosocial Stressors
• Describe the most significant stressors
• Any immediate safety concerns in the home or care setting?
• Describe the safety concern and any immediate action taken

Support System and Caregiver Capacity

• Is a primary caregiver available?
• Caregiver capacity at this time
• Caregiver burden indicators
• Describe caregiver support needs

Resources, Benefits, and Referrals

• Current Resource Needs
• Benefits or coverage concerns
• Referrals made today
• Referral details and follow-up plan

Intervention Plan and Documentation

• Initial MSW Intervention Plan
  Summarize counseling, education, advocacy, referrals, and coordination steps.
• Is follow-up needed?
• Preferred Follow-up Date
• Medical Social Worker Signature