Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.61(a)(4) The social service records, including reports of interviews with patients, family members, and others, must provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.

## Interpretive Guidelines §482.61(a)(4)

The purpose of the social work assessment is to determine the current baseline social functioning (strengths and deficits) of the patient, from which treatment interventions and discharge plans are to be formulated.

Patient length of stay is a key factor influencing hospital documentation policy, i.e., establishing timeframes for completion, documentation, and filing of the psychosocial assessment, and treatment planning in the medical record.

A psychosocial history/assessment must be completed on all patients. Three key components to be addressed:

- A. Factual and Historical Information
1. Specific reasons for the patient's admission or readmission;
2. A description of the patient's past and present biopsychosocial functioning;3. Family and marital history, dynamics, and patient's relationships with family and significant others;
4. Pertinent religious and cultural factors;
5. History of physical, sexual and emotional abuse;
6. Significant aspects of psychiatric, medical, and substance abuse history and treatment as presented by family members and significant others;
7. Educational, vocational, employment, and military service history;
8. Identification of community resources including previously used treatment sources;
9. Identification of present environmental and financial needs.
- B. Social Evaluation
1. Patient strength and deficits;
2. High risk psychosocial issues requiring early treatment planning and intervention - i.e., unattended child(ren) in home; prior noncompliance to specific treatment and/ or discharge interventions; and potential obstacles to present treatment and discharge planning.

## C. Conclusions and Recommendations

Assessment of Sections A and B shall result in the development of (C) recommendations related to the following areas:

1. Anticipated necessary steps for discharge to occur;
2. High risk patient and/or family psychosocial issues requiring early treatment planning and immediate intervention regardless of the patient's length of stay;3. Specific community resources/ support systems for utilization in discharge planning - i.e., housing, living arrangements, financial aid, and aftercare treatment sources;
4. Anticipated social work role(s) in treatment and discharge planning.

## Survey Procedures §482.61(a)(4)

Does the psychosocial history/assessment indicate:

1. Clear identification of the informants(s) and sources of information?
2. Whether information is considered reliable?
3. Patient participation to the extent possible in provision of data relative to treatment and discharge planning?
4. Integration of significant data including identified high risk psychosocial issues (problems) into the treatment plan?
5. How does the hospital insure the information is reliable?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "psychosocial history/assessment"}, "rule_type": "existence", "scope_tags": ["clinical", "legal"]}