How to Document a Medical Social Work (MSW) Order
Document the specific reason for the MSW referral by identifying the patient's psychosocial or practical problem, then place this documentation in the medical record with clear indication of the problem severity and expected intervention type.
Indications for MSW Referral
Social work services should be ordered when a patient presents with either psychosocial or practical problems 1:
Practical Problems
- Illness-related concerns and concrete needs (housing, food, financial assistance, help with activities of daily living, transportation) 1
- Employment, school, or career concerns 1
- Cultural or language issues 1
- Caregiver availability concerns 1
Psychosocial Problems
- Adjustment to illness 1
- Family conflicts and social isolation 1
- Difficulties in decision-making 1
- Quality-of-life issues 1
- Advance directives 1
- Domestic abuse and neglect 1
- Coping or communication skills deficits 1
- Functional changes (body image, sexuality) 1
- End-of-life and bereavement issues 1
Required Documentation Elements
Your MSW order documentation must include these specific components to meet professional standards:
Patient Identification and Problem Specification
- Patient's name and date of birth 1
- Date and time of the order 1
- Specific reason for referral (identify which practical or psychosocial problem from above) 1
- Problem severity level: mild, moderate, or severe 1
Clinical Context
- Relevant patient history related to the social work need 1
- Assessment of the issue requiring social work intervention 1
- Any identified social support deficits (e.g., "Who can help in case of emergency?") 1
- Documentation of instrumental or emotional support gaps 1
Expected Intervention Type
For mild problems, document need for 1:
- Patient and family education
- Support group referrals
- Local resource information
For moderate-to-severe problems, document need for 1:
- Counseling and psychotherapy
- Community resource mobilization
- Problem-solving interventions
- Advocacy and protective services
Documentation Placement and Format
- All MSW order documentation must be placed in the patient's medical record 1
- Use clear, brief language that emphasizes clinical usefulness over billing requirements 1
- Document the type of encounter to demonstrate complexity of decision-making 1
- Include disposition and plan following the MSW consultation 1
Special Populations Requiring MSW Documentation
Older Adults with Cancer
When ordering MSW for geriatric oncology patients, specifically document 1:
- IADL deficits (any items requiring "some help") 1
- Social support screening results (instrumental or emotional items with "none, a little, or some of the time") 1
- Need for home health aide evaluation if criteria are met 1
- Need for on-person lifeline emergency service 1
Patients with Distress
Document screening results and specific distress-related needs when ordering MSW for anxiety, depression, or adjustment disorders 1
Common Pitfalls to Avoid
- Do not use vague language like "social work consult" without specifying the problem type and severity 1
- Do not delay documentation until discharge—MSW services are most effective when provided upon admission rather than at discharge 2
- Do not omit severity assessment—interventions differ significantly between mild versus moderate-to-severe problems 1
- Avoid documentation solely for billing purposes—focus on clinical usefulness and continuity of care 1