Section 8: The More Comprehensive Psychosocial Assessment

For persons with complex social, psychological and medical needs, particularly complex co-morbid conditions, a more comprehensive bio-psycho-social assessment of the presenting problem is generally recommended, one that includes an historical and prognosis time frame, as well as the current time window. This would be  used to expand upon what is described in the narrative Presenting Problem section. All of the other sections of the assessment form would remain largely the same.

A good choice to use for this more complex examination of the presenting problems would be the Intermed Complexity Assessment Grid (Stiefel et al., 2006). This will be presented below. This tool addresses four anchor points and three time frames as points of focus for this part of the assessment. This creates 12 different vectors, recorded to identify areas that need immediate attention from those that require long term intervention or monitoring or no intervention at all. The four anchor points consist of the Biologic, the Psychologic, the Social and the Health Care Domains. The three time frames consist of the past, present and future, in the form of the Historical, Current Functioning, and Anticipated Needs (Prognosis). Here is the general shape of this format in visual form.

In the Biologic or Medical Domain, medical issues are evaluated historically for their chronicity and clarity of diagnosis. In the Current state the severity of symptoms, as well as the clarity of diagnosis, is reviewed. In the Anticipated Needs or prognosis vector, information relates to complications and life threat. Medical conditions that might be considered life threatening would include delirium, organ failure, heart attack, uncontrolled infection or bleeding.

In the Psychologic Domain, the person’s psychiatric condition is evaluated historically by identifying restrictions in coping or dysfunction. In the Current state, it is examined whether the person has active psychiatric symptoms and/or whether they are resistant to treatment. In the Anticipated Needs or prognosis cell, any mental health threat is identified, for example the risk of being a danger to self or others.

The Social Domain focuses historically on any identified restrictions in social integration or evidence of social dysfunction. In the Current state, residential stability and restrictions within the social support network are categorized. In the Anticipated Needs or prognosis cell the person’s social vulnerability is identified.

The Health Care or Systems Domain identifies historically the intensity of previous medical/psychiatric treatment as well as the person’s perception of their treatment experience. In the Current state, the person’s organization of care and appropriateness of referrals are evaluated. In the Anticipated Needs or prognosis cell, issues with coordination of care are identified. This domain can also include important information about a person’s financial stresses, access to services, cultural barriers, and other items that can affect how well therapeutic services will be used.

This bio-psycho-social-systems approach can be utilized for complex cases with children and adolescents, as well as adults. You would typically record relevant information about the client’s family and any problems in that part of the child’s support system that must be addressed as part of treatment in the support domain.

This format can also be transferred over from the assessment phase into the development of a complex treatment plan and a system for tracking the implementation of that treatment plan. For more complex cases, with multiple providers and/or case management activities, it is usually insufficient to operate with a one page treatment plan and a simple progress note. This grid format is a very efficient way of visualizing and tracking a complex treatment plan that covers many areas of intervention.

As previously noted, for an expanded view of how to build a psychosocial assessment form for more complex cases, please consider taking yourceus.com's course PSA6669.

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