When and how should you document a referral to a cultural liaison or social worker?

• A. In the Assessment section
• B. In the Plan, with reason for referral, expected outcomes, and follow-up timeline
• C. In the Patient's notes
• D. In the discharge summary

Answer: (B)

The main idea is that referrals to a cultural liaison or social worker are part of the plan of care, so they belong in the Plan section of the SOAP note. In this section you lay out what actions will be taken, including why the referral is needed, the expected outcomes, and the follow-up timeline. Documenting all of this together makes the referral actionable and trackable, guiding the patient’s ongoing care and ensuring the team knows who will do what and when to check back.

Placing the referral in the Assessment would mix clinical reasoning with planning, making it harder to see what actions will follow. The discharge summary is about summarizing care at the point of discharge, not about detailing ongoing steps, and the patient’s notes alone may not clearly communicate the plan and responsibilities.