SW Coordination Note

EDIE · PointClickCare · Epic
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Date:
Admitted:
Reason for ED Visit
Intoxication Health concern Chronic illness Other
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SW Interaction Type
Initial contact Follow-up Crisis intervention Provided clothing/food Discharge coordination Assisted with discharge plan Placement coordination Resource linkage APS/CPS reporting Other
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Discharged to:
Shelter Drop-in shelter RSOC Home Treatment facility Other
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Current Need
Housing Substance use support Mental health support Caregiver support Transportation Insurance/financial Placement DV/safety Food insecurity Medication access End of life Other
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What SW Did
Resources provided Collateral obtained and documented Warm handoff completed Referral submitted Coordinated with family Coordinated with outpatient team Transportation arranged APS/CPS report filed Safety planning completed Patient declined services Other
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Referrals
Placement
SoMa RISE Harbor Light Shelter Drop-in Shelter A Woman's Place Other
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Community
ECM OCC Other
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Engagement
Engaged/cooperative Limited engagement Agitated Unable to assess Somnolent/intoxicated Family primarily engaged Repeatedly declines support Other
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Known Barriers
No phone No transportation No PCP Unhoused Cognitive impairment Active substance use Psychiatric instability Insurance barrier Limited support system Frequent ED utilization Health literacy concerns Other
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Risks
SUD High utilizer High readmission risk Unsafe discharge concern Other
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History of Agitation / Violence
Verbally abusive Physically abusive Other
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De-escalation recommendations
See guidelines: edie.pages.dev
Existing Supports
ECM BH case management Conservator Home health Hospice IHSS Family involved Shelter/navigation center SNF/LTC resident None known Other
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Disposition Status
Cleared from SW perspective Ongoing SW needs Unsafe discharge concern Placement pending Awaiting psych placement Awaiting medical clearance Other
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Recommendations
Provide food prior to engagement Meet with two providers at once Remove all objects from room Other
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Additional Notes 2–3 sentences · no PHI
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