How to Write a First Interview Summary Case Note If You Are a Medical Social Worker

by Ashley Miller Google

Medical social workers are health professionals who work in hospitals, outpatient medical clinics, substance abuse treatment facilities and other health-care organizations. Documentation of all patient contact is one of the main responsibilities of a medical social worker. After the initial assessment, a medical social worker must complete a first interview summary case note that provides comprehensive biopsychosocial information, subjective impressions and treatment recommendations.

Presenting Problem

The term "presenting problem" is used to describe the reasons the patient was admitted to the facility or decided to come for treatment. During an initial interview, a medical social worker directly asks the patient why he is seeking treatment, if it isn't readily apparent. The social worker also gathers basic identifying information, such as the patient's age, sex and race. Medical social workers must document the patient's description of the presenting problem as well as try to obtain outside information, if possible, from other involved professionals, such as referring physicians. The presenting problem is usually written as the first sentence of the case note. For example, you might write, "John Jones is 39-year old Caucasian male presenting for treatment due to a fractured hip."

Biopsychosocial Information

Biopsychosocial information-gathering involves taking a comprehensive look at all of the biological, psychological and social aspects of the patient's life. It focuses on teasing out information that might have a direct impact on the presenting problem. During this process, you obtain detailed information about the patient's medical, psychiatric, social and work history. If the patient is not able to speak for himself, the social worker might need to ask other involved parties, such as family members, for this information. This information is documented in the case note following the presenting problem.

Clinical Impressions and Analysis

A first interview case note includes your subjective impressions of the patient, including behavior, eye contact, speech, coherence and mood, and a brief summary of your interpretations of the interview. For example, after the presenting problem and biopsychosocial information, you would write whether the patient seemed cognizant, engaged, cooperative, energetic or depressed, or anxious. Following this information, you would note any additional subjective information about your interview that would be helpful to other medical professionals reading your case note, such as whether the client appears open or resistant to treatment.

Treatment Plan and Conclusion

The recommended course of action, including goals and a suggested course of treatment, if applicable, is the final part of a first interview summary case note. This section includes information such as referrals to other medical professionals or the steps the patient must take immediately following your interview. For example, you might write, "Referred patient to the psychiatric unit for an evaluation and diagnosis." After your case note is completed, you must sign and date the document and insert it into the patient's file.

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