Medical Social Work Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

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GENERAL KNOWLEDGE/SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

National Patient Safety Goals	123
CMS: Centers for Medicare and Medicaid Services	123
Awareness of HCAHPS scores	123
Knowledge of Advance Directives	123
HIPAA: Health Insurance Portability and Accountability Act	123
Disability Management	123
Worker’s Compensation	123
Discharge planning	123
The Joint Commission	123
Universal Precautions	123
Cardiac Arrest/CPR/AED	123
Rapid Response Teams	123

KNOWLEDGE OF ASSESSMENT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Health History, review of physical examination, review of systems	123
Psychosocial Assessment (social history, support systems, emotional, caregiver support, ability to deal w/loss)	123
Financial Assessment (income, ability to manage needs)	123
Emotional Assessment (response to illness, treatment, support)	123
Spiritual Assessment (religion, beliefs, practices and relationship to care)	123
Terminal Care Assessment (5 stages of grief, hospice, palliative care, crisis)	123
Development of problem list	123
Perform Initial Evaluation	123
Develop and revision of care plan	123
Assess outcome to treatment	123
Establish and revision of goals	123

DOCUMENTATION SKILLS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Initial assessment and treatment plan	123
Skilled visit notes	123
Follow Physician orders	123
Documents according to POC	123
Documents key information to physician, supervisor and case manager	123
Discharge Summary	123

PLAN OF CARE AND COORDINATION:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Follows Plan of Care	123
Review POC prior to care	123
Communicate and Coordinates with interdisciplinary team members	123
Knowledge of criteria for participation in Medical/State Regulations	123
Knowledge of skilled reimbursable visit	123
Effective Case Coordination	123
Knowledge of available community resources	123
Community Resource Planning	123
Attends case conferences as required	123

INFECTION CONTROL:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hand washing	123
Exposure plan	123
Utilizes Personal Protective Equipment PPE	123

PATIENT EDUCATION:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Determine learning needs	123
Set goals/objectives	123
Develop and implement care plan	123
Evaluate effectiveness of teaching	123
Ability to revise care plan	123

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hospital	123
Hospice	123
Military base or Veteran Affair Clinic	123
Long Term Care	123
LTAC	123
Schools	123
Community Mental Health Agency	123
Correctional Facility	123
Private Practice	123
Substance Abuse Clinic	123
State/Local Government (Dept HHS, Child Welfare, Jobs and Family Services)	123

AGE-SPECIFIC EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn/Neonate (birth to 30 days)	123
Infant (31 days to 12 months)	123
Toddler/Preschool (13 months to 5 years)	123
School Age Child/adolescent (6 years to 18 years)	123
Young Adults/Middle Adult (19 years to 64 years)	123
Older Adults/Elderly (65+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *