A Structured Template for Social Work Psychosocial Assessments and Formulations in Healthcare

ABSTRACT

Previously, substantial inconsistencies existed in relation to social work documentation in medical records across Queensland Health. A structured, adaptable social work psychosocial assessment template, developed for use across Queensland Health, is introduced in this article. This template comprises six title headings and encompasses nine psychosocial domains. Importantly, a “Care Needs and Choice” domain encouraged promotion of the “patient voice”, while a Clinical Formulation section and matrix encouraged analysis and assessment of the presenting situation as conceptualised through the social work lens. We propose that, together with AASW guidelines and resources (e.g., AASW Practice Standards, 2023), utilisation of this template can help social workers articulate their professional identity and demonstrate their unique contributions to holistic, person-centred psychosocial healthcare.

IMPLICATIONS

• A structured adaptable template can assist social workers to document psychosocial assessments in the medical record.

• Use of this template can help demonstrate the professional scope of social work practice and social workers’ unique contributions to person-centred care.

• The template promotes consideration and documentation of the “patient voice”, and the Formulation matrix encourages critical thinking and analysis to inform social work interventions.

KEYWORDS:

• Social Work
• Psychosocial Assessment
• Patient Perspective
• Documentation
• Social Work Clinical Formulation
• Medical Record

Acknowledgements

We thank QH social workers who trialled draft templates, and Robert Bland and Donna McAuliffe for feedback on draft manuscripts.

Disclosure Statement

The authors report there are no competing interests to declare. All authors are employed as social workers or social work educators in Queensland Health.