When the Note Doesn’t Fit: Social Workers Documenting in the Electronic Health Record on Integrated Health Teams

Abstract A qualitative study was conducted to understand how social workers document their work in the electronic health record (EHR) in integrated primary care settings. Three themes emerged from the analysis of the focus groups: 1) considerable variability in where and how social workers document their practice within the EHR; 2) EHR functions are not designed for social work practice; and 3) EHR documentation practices as helpful for demonstrating social workers’ contributions to other integrated care team members. Education, training, and EHR adaptations are needed as social workers and other nontraditional healthcare providers continue to partake in team-based service delivery, especially in integrated primary care.