Professionalism in Healthcare Social Work Practice & Developing Patient / client case notes

1. Professionalism in Healthcare Social Work Practice & Developing Patient / client case notes John V. Silipigni, LCSW, MBA, CCM, ACM-SW October 9, 2019

2. Professionalism

3. HEALTHCARE ORGANIZATIONS • Healthcare organizations are typically very traditional, conservative organizations. • Medical practice is based on research over the lifespan. • Change is slow.

4. First impressions • You have just 7 seconds to make a first impression…make them count! • It’s what you say. • It’s the way you say it. • Its what you do while you’re saying it.

5. First Impressions

6. First impressions What’s your first impression?

7. Second Impressions

8. Second impression What’s your second impression?

9. Implicit Bias?

10. What you say… • Use courteous & welcoming words - • Good morning • Welcome back • How may I help you? • Use helpful words - • Certainly • I’d be glad to…. • This is what I can do. • Is there anything else I can do for you? • Avoid impersonal or negative language - • I’m too busy. • We’re short staffed. • We had a call-off this morning. • I have to cover another unit today. • You didn’t fill this out right. • You didn’t do what I asked you to do.

11. The way you say it… • Face to face communication - • 38% of your message is communicated through the tone of your voice. • Telephone communication - • 86% of your message is communicated through the tone of your voice. • Improve your tone - • Use a friendly tone and unhurried pace. • Smile – even when you are on the phone. • Use a variety of voice inflection to keep the listener’s attention. • Email communication – • Timely response. • Pause before hitting the send button. • Review and check the tone of your email…does it reflect the feeling in which what you want it to reflect?

12. What you do while you’re saying it… • It’s all about your body language - • Facial expressions. • Appropriate eye contact. • Posture and proximity. • Gestures (eye rolling, sighing, crossed arms, giggling, etc.) • It’s all about your appearance - • ID badge visible. • Appropriate attire and personal appearance. • Avoid eating/drinking in front of patients. • Avoid a messy, disorganized workspace. • Pick up trash, clean up after yourself! • It’s all about your actions - • Give patients the courtesy of going first on elevators, stairs, doorways, etc. • Offer to help those who look lost or confused. • Knock before entering a patient room. • Take work breaks in non-public areas. • Take private conversations to private locations. • Don’t be distracted by your smartphone. • Don’t be rude or insensitive.

13. BECAUSE… You Never Get a Second Chance to Make a First Impression!

14. AIDET www.studergroup.com • A.I.D.E.T. - • Acknowledge • Introduce • Duration • Explanation • Thank You

15. Organizational Policies Review your organization’s policies – • Dress Code Policy - • Clothing / Uniforms • Stockings / Socks • Shoes • Undergarments • Tattoos • Body Piercings • Smoking

16. NASW Code of ethics

17. Social media

18. PROFESSIONALISM https://www.youtube.com/watch?v=Uo0KjdDJr1c

19. The Essence of Professionalism • Professionalism - • Dress and Grooming. • Attendance. • Behavior and attitude. • Indentity with social work as a profession. • Use of time. • Adherence to basic principles of social work practice. • Going the extra mile. (Wilson, Suanna J., Field Instruction,1981)

20. Developing patient / client notes - documentation

21. Documentation • Documentation - • The purpose of documentation: • Provide an accurate and standardized account of the information gathered. • Support this information with introspective and retrospective data collection. • Provide the information needed for good practice standards that include relevant ethical, legal, billing and agency requirements. • Provide clearly stated information that will withstand scrutiny by external reviewers such as accreditation bodies, ombudsmen, lawyers, insurance companies and quality assurance/improvement and control personnel. • Critical to complete…however it is the least productive task that a social worker must complete in a given day!

22. The #1 golden rule for Documentation

23. Do’s and Don’t of documentation DO’s DON’TS Alter a record. Use biased language. Use vague language – “a lot” Use slang, street language, jargon or profanities unless in quotations. Use personal opinions without facts that might back up that opinion. Use ambiguous terms that someone reading may ask the question: “I wonder what that means?” Write in code so that no one will understand. Write about personal details that don’t impact the case. • Check to assure that you are documenting on the correct patient. • Date and time your note if not done electronically. • If you’ve documented in error – place a strike out line through the note, write error and initial. • Be clear, concise, factual and brief if possible. • Document what you see, hear, feel or smell. • Be clear about frequency and intensity. • Consider the audience reading your note. • Write enough to tell the whole story with the understanding that someone else may read that story and comprehend it.

24. Observations • Interventions • Next Steps • Follow-up • Homework • Outcomes

25. DOCUMENTATION STYLES

26. Documentation styles

27. Documentation styles

28. Practice time! https://www.youtube.com/watch?v=67I6g1I7Zao&t=2s

29. CORE COMPETENCIES IN INTEgrated healthcare • Interpersonal Communication • Collaboration and Teamwork • Screening & Assessment • Care Planning & Care Coordination • Intervention • Cultural Competence & Adaptation • Systems Oriented Practice • Practice-Based Learning & Quality Improvement • Informatics

30. Discussion Discussion

31. references • Dziegielewski, Sophia F. and Diane C. Holliman, 2020, The Changing Face of HealthCare Social Work: Opportunities and Challenges for Professional Practice, New York, Springer Publishing House, Chapter 7 – Documentation and Record Keeping in the Health Care Setting, 149-181. • NASW Code of Ethics. • Reamer, Frederic, October 2005, “Documentation in Social Work: Evolving Ethical and Risk Management Standards,” Social Work, vol. 50, no. 4., p 325 – 334, National Association of Social Workers. • SAMHSA – HRSA, Center for Integrated Health Solutions, January 2014, “Core Competencies for Integrated Behavioral Health and Primary Care,” www.integration.samhsa.gov • Studer Group – AIDET – www.studergroup.com • Wilson, Suanna J., 1981, Field Instruction: Techniques for Supervisors, New York, The Free Press. • Youtube.com - ”Motivational Interviewing – Good Example – Alan Lyme,” https://www.youtube.com/watch?v=67I6g1I7Zao&t=1s