Encounter Documentation
You are actively engaged with a patient. Do you assign yourself to the care team?
What is YES
True or False: Episodes stay open indefinitely unless the patient requests closure.
What is false
True or False: It is the expectation of the system that all ACM Social workers are using Epic's connection to community to log or when able send direct referrals to community-based organizations.
What is TRUE
Which report shows your current patient list that you are assigned on the care team AND have an open episode with?
What is "AMB Find My Patients with Active Social Work Episodes" report
You should be running this report weekly if not daily for your follow ups.
True or false: If you are actively engaged with a patient, you should be filling out the "SW Assessment" template to the best of your ability and pulling that into your note. (Excluding Women's Health)
What is TRUE
You can delete any irrelevant information in your note.
If you were unable to reach them on the first outreach attempt and were able to on the 2nd this should be completed then.
You should be choosing a reason for referral from the drop-down menu
In rare cases where a full assessment is not able to be completed, you may utilize the smartphrase .MLHCSWREASONFORREFERRAL
Scenario: You are meeting a patient in-person at the office. What encounter type would you document?
What is Social Work Encounter
Scenario: You were once actively engaged with a patient but they have not returned 2 voicemails you have left. Should you leave the episode open hoping they will reach back out?
What is no
Close "resolve" the episode. You can always reopen the same one if they call back within reasonable time frame.
Scenario: You provided outpatient mental health resources to a patient. Should you follow up?
What is YES
Follow up is crucial regardless of referral reason unless a patient specifically declines.
Follow up timeframe is based on patient's need and clinical judgement. Typically 1-2 weeks.
Which report shows you patients you opened with active social work episodes?
What is "MLHC - Social Work Open Episodes RWSQL Report"
You should be running this report at least quarterly
True or false: You are only expected to clear out your in-basket when you have planned upcoming time off.
What is FALSE.
All social workers are expected to actively manage and clear their in-baskets consistently. This ensures safe, efficient coverage when you’re out and prevents delays in patient care. Messages or pending follow-ups should not sit longer than 2 weeks without action or appropriate handoff.
Scenario: You are calling a patient, what encounter type would you document?
What is Patient Outreach Encounter
Scenario: Patient is verbally abusive during a phone call. What should you do?
What is consult a team lead, or manager
What is close "resolve" the episode
What is document in RL Datix
What is use the "Closing Abusive Pt's" SmartPhrase in your note
True or False: ALL social workers should be completing the SDOH assessment on patients if it has not already been completed within the last year?"
What is TRUE
We assess five components in the SDOH assessment: Transportation, Housing, Utility Bills, Food Insecurity, and Financial Resource Strain.
Questions must be asked verbatim to ensure consistency and accuracy.
The assessment is completed directly in Snapshot, not just documented in your note.
Currently, only Primary Care and LOGCC receive referrals from patients who have completed the assessment:
How often should you be logging your referrals on the "SW Productivity log"?
What is daily
True or false: MLHC Care Management does NOT have a transportation budget.
What is false
This can be utilized only as a last resort, one time use.
You should be notifying your manager when requesting a ride with the patient information, and cost.
BMFP has their own transportation budget and can be utilized when arranging in Epic under that department.
True or false: You should ALWAYS be notifying the referral source of your outcome or attempts to outreach the patient?
What is TRUE
This can be done by replying back to their in-basket message or sending your chart note directly to them.
Scenario: You call a patient after a hospitalization but only reach voicemail. Do you open an episode?
What is no
How long do you have to respond to a referral?
What is 24-48 business hours
When a referral from the SDOH self-questionnaire comes to the pool how do you know if it is your patient?
What is by checking the "Appt Dept" column
You can "take the baton" but best practice would be to forward referral to yourself and follow up to keep the pool clear
Scenario: You received a referral, attempted to outreach but got their voicemail. When should you attempt your second outreach?
What is 1 week (7 days) later.
Scenario: You receive a referral from the office RN for in-home services but got the patient's voicemail. You document the call, assign yourself to the care team, and write your note. Do you sign the encounter?
What is no
You do not sign the encounter so it stays in your open encounters folder in your in-basket. When you follow up- you document your 2nd attempt in the same encounter note.
Scenario: You haven’t spoken to a patient in 65 days. What’s the workflow? (Excluding Women's Health)
What is close "resolve" the episode
What is take yourself off the care team
Scenario: A physician sent you a referral to contact a patients step-daughter because she keeps calling into the office. What should you do first? (hint: think HIPPA)
What is check the PHI form
Do you make an outreach to SDOH questionnaire referrals before the patient is established at the practice?
What is NO
Scenario: You receive a referral for a patient from MLHC OB/GYN Wynnewood who does not have a MLHC PCP. What do you do?
What is consult your team lead or manager
What is send referral to the "community health worker p" in epic