Transforming Social Work Documentation across the Sunshine State: A state-wide chart audit exploring the implementation of standardised Psychosocial Assessment Templates in Queensland Health

Mrs Kim Sutherland1, Ms Sue Cumming1, Dr Simon Finnigan2, Ms Kellie Young3, Ms Gisele  Rossini4, Ms Katherine  Allen5, Ms Annette  Hodgkinson5, Ms Chezz Viner-Pallier5, Dr Laurelie Wishart2

1Princess Alexandra Hospital, Metro South Health, Brisbane, Australia, 2Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia, 3Gold Coast University Hospital, Gold Coast Health, Gold Coast, Australia, 4Cairns Base Hospital, Cairns Health, Cairns, Australia , 5Toowoomba Base Hospital, Darling Downs Health, Toowoomba, Australia

Introduction: In 2019 the Queensland Health (QH) Social Work and Welfare Clinical Education Program (SWWCEP) released a guide benchmarking a standardised health record documentation template for Social Work Psychosocial Assessments (SW-PSA). This guide constitutes a best practice tool for all QH SWs and was released together with a professional development and education strategy designed to promote awareness and educate SWs and students.

Aim: The primary aim of this project was to investigate whether the implementation of the SW-PSA guide and education strategy improved the quality and consistency of SW documentation, across four QH hospitals (in accordance with best practice principles outlined in the guide).

Methods: SW chart entries (initial or review, inpatients or outpatients) in the QH medical record during pre- and post-implementation periods (September 2018 and 2019, respectively) were audited from selected sites. For each site, a 10% sample was randomly selected for audit (712/7123 total). De-identified entries were rated by the investigators (SWs) across a range of quality metrics using a purpose-built tool informed by best practice principles identified in the SW-PSA guide/SW National Practice Standards (2013). Descriptive statistics were computed regarding numbers of entries attracting given responses to each of the 14 audit criteria.

Results: The SW-PSA template was employed in 73% of post-implementation entries. Critical information was missing in 39% of entries not utilising the template, whereas it was never missing when the complete template was used.  Several salient results emerged, including variability between sites and a significantly low proportion of SW analysis demonstrated in clinical formulation, both in pre- and post-implementation entries.

Discussion / Implications: This project has delivered greater understanding of how the SW-PSA guide and templates are informing practice and standards, and insights regarding future training initiatives.


‘Biographies to come’.

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