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Four: Taking a Medication History, Documentation, and Treatment Planning

DOI:

10.1891/9780826130389.0004

Abstract

This chapter focuses on using the skills of the social worker to support the health care delivery team. In order to complete the advocacy and broker functions basic in the field of social work, an accurate assessment and referral process in regard to medication use must be utilized. As part of the assessment process, a medication history needs to include the client's patterns of medication use, preference, and potential for (or history of) abuse. Every record must have basic information, including the date and time of entry, interview notes describing the client and the problem or situation requiring treatment, an assessment and initial treatment plan, and therapeutic objectives and treatment responses. An accurate and responsible history should also explore the possibility of medication abuse. When the potential for abuse is high, social workers can prepare the team to be aware, thus avoiding possible problems for the client.