Documentation follows best practices |
The psychosocial evaluation does not follow the general norms for clinical documentation, and the documentation contains many major problems. |
The psychosocial evaluation generally follows the norms for clinical documentation but has some more significant errors or problems found in the documentation. |
The psychosocial evaluation generally follows the norms for clinical documentation but has a couple of areas with more minor errors or problems. |
The psychosocial evaluation follows general norms for clinical documentation in how it is written. Examples include using professional and neutral language, writing with clarity and precision, balanced use of subjective and objective information with clear distinctions, use of client-centered language, and a cogent organizational style. |
The evaluation will be comprehensive gathering the necessary information about client needs |
The psychosocial assessment greatly lacks the information needed for a comprehensive psychosocial evaluation. |
The psychosocial assessment is missing one or two of the required sections to provide a comprehensive evaluation. Many of the sections seem underdescribed and appear to be missing relevant information that should have been gathered. |
The psychosocial assessment gathers information about the client’s needs in all required areas. One or two sections are underdeveloped and appear to be missing relevant information. |
The information gathered in the psychosocial evaluation will provide a comprehensive overview of the client’s needs. It will include information collected related to identifying information, referral source, presenting problem, developmental assessment, family background, personal history, medical history, educational/learning history, social class, cultural history, religion/spiritual, mental status and current functioning, summary, recommendations, and intersection client/worker relationship. |
The evaluation contains alignment and develops a deep understanding of the client |
There is a lack of alignment between what is presented in the client’s history/presenting problem and the interpretations and recommendations made in the assessment. |
The assessment has more significant problems with alignment between the client’s history/presenting problem and the interpretations and recommendations made in the evaluation. |
The assessment generally aligns with the description of the client’s history/presenting problem and the clinician’s interpretations and recommendations. There are some minor discrepancies, where it appears the information was not collected or was unnoticed by the writer. |
The assessment develops a complete picture of the client. The information gathered about the client’s history/presenting problem sections connects to the social worker’s interpretations and recommendations (e.g., mental status, summary, and recommendations). Any significant discrepancies are discussed. |
Following Assignment |
The case study does not follow the assignment description and requirements. |
The case study somewhat follows the assignment description, but significant errors exist. |
The case study follows the assignment description and requirements but has minor errors. |
The case study closely follows the assignment description and requirements. |