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.


Kim Sutherland is the State-wide Clinical Education Practice Lead for Social Work, supporting a large team of Clinical Educators (CESOs) across Queensland to manage student placements, as well as the professional development needs of social workers in Queensland Health.

After graduating from the University of Queensland in 2003, Kim went on to receive a Diploma of Practice Teaching from the University of Kingston in 2007.   Kim has experience in the field of Child Safety, both in England and Australia, holding several management portfolios in the London Borough of Richmond from 2006 to 2008.

Kim joined Queensland Health in 2010 where she worked extensively across the Division of Cancer Services, before joining the State-wide Clinical Education Program in 2018, where she could foster her passion for education and leadership.

Kim is the project lead for both the Social Work Psychosocial Assessment Project and Social Work in Health New Graduate Program.  Kim designed, developed, and delivered content and education strategies in collaboration with key stakeholders, initiating a state-wide change management process guided by evidence and best practice standards.

In her ‘spare’ time Kim works with inter-professional, university and social work colleagues on projects close to her heart.  This includes the delivery of CARE (Communicating Actively, Responding Empathically) workshops, being Co-Convenor of Palliative Care Social Work Australia (Qld Network), and co-collaborator on a staff student research project with UQ, looking at student experiences of interprofessional education in life-limiting illness.

Kim is currently the PI for the Social Work Psychosocial Assessment Research Project.

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