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PSA6669 - SECTION 13: COMPREHENSIVE PSYCHOSOCIAL ASSESSMENT TEMPLATES

 

There are many elements that influence our ability to function, our perceptions, decisions, preferences, behaviors, goals and aspirations. In order to identify strengths and barriers, there needs to be a kind of inventory of physical (medical), behavioral (psychologic), social (environmental) and health care experiences (systems).

The following template contains inventory tools to track where real and potential strengths and challenges exist so that the individual being assessed and the practitioner doing the assessment have clear and specific anchors to develop a viable and relevant intervention plan.  



                                            ASSESSMENT FORM

Demographic Information:

NAME_________________________ DATE OF ASSESSMENT: ______________
ADDRESS: ______________________ CITY/STATE/ZIP _____________________
HOME PHONE: __________________ WORK PHONE: ______________________
EMERGENCY CONTACT: ________________________ RELATIONSHIP: ______
EMERGENCY CONTACT ADDRESS: _____________________ _________
EMERGENCY CONTACT PHONE: _______________________________________
PCP NAME: ______________________________ PCP PHONE: ________________
PCP ADDRESS: _______________________________________________________
INSURANCE PLAN: ____________________ INSURANCE ID#: ______________

If a minor child:
PARENT NAME: ________________________ PARENT PHONE:______________
PARENT ADDRESS: ___________________________________________________
PARENT AUTHORIZATION* FOR ASSESSMENT [] YES [] NO
*Both parents must authorize or provide documentation that the authorizing parent has court ordered sole custody.

DEMOGRAPHIC INFORMATION (verify with appropriate documentation)

NAME_________________________ DATE OF ASSESSMENT: ______________
ADDRESS: ______________________ CITY/STATE/ZIP _____________________
HOME PHONE: __________________ WORK PHONE: ______________________
EMERGENCY CONTACT: ________________________ RELATIONSHIP: ______
E-CONTACT ADDRESS: ______________________________________________
E-CONTACT PHONE: __________________________________________________
PCP NAME: ______________________________ PCP PHONE: ________________
PCP ADDRESS: _______________________________________________________
INSURANCE PLAN: ____________________ INSURANCE ID#: _______________

If a minor child:
PARENT NAME: ________________________ PARENT PHONE:______________
PARENT ADDRESS: ___________________________________________________
PARENT AUTHORIZATION* FOR ASSESSMENT [] YES [] NO
*Both parents must authorize or provide documentation that the authorizing parent has Court ordered sole custody.

CLIENT’S DESCRIPTION OF THE CHIEF CONCERN/COMPLAINT; PRECIPITATING EVENT; SIGNS AND SYMPTOMS and /or HISTORY OF PROBLEMS:








PERSONS PARTICIPATING IN THE PSYCHOSOCIAL ASSESSMENT PROCESS and their relationship to the person seeking the psychosocial assessment.




MEDICAL - Four Dimensions (related to physical issues only) 
Historical
Current/Anticipated NeedsCase Management Activities, and Clinical Intervention 

 

Historical
Current
Anticip
Clinical Interven
 
 
 
 

 

 

PSYCHOLOGICAL - Four Dimensions (Related to behavior, mental health and substance use disorders)

 

Historical
Current
Anticip
Clinical Interven
 
 
 
 

 

 

SOCIAL - Four dimensions (related to job, leisure, social dysfunction, residential stability, social support or social vulnerability)

 

Historical
Current
Anticip
Clinical Interven
 
 
 
 

 

 

SYSTEMS - Four dimensions (related to Language, Religious, Cultural, Health)

Historical
Current 
Anticip
Clinical Interven
 
 
 
 

 

 

 

Risk Assessment

Suicide     __None  __Ideation  __Intent  __Plan  __Means  __Attempt

Explain:

Homicide __None  __Ideation  __Intent  __Plan  __Means  __Attempt

Explain:

Physical/sexual abuse:          _ _Denies           ___Yes 

Explain: 

Child/elder neglect or abuse:_ _Denies           ___Yes 

Explain: 

 

Coping Resources (Include coping skills/deficits, social supports, hobbies, exercise, nutrition, etc.)

 

 

Diagnostic Impressions/Therapeutic Recommendations:

 

Dx:  _________________________________________     Code: _________

Dx::  _________________________________________    Code: _________

Dx:__________________________________________     Code: _________

Dx: _________________________________________     Code: _________

Dx::_________________________________________     Code: _________

Dx::_________________________________________     Code: _________

 

Disposition/Referral:

 

 

 

Prognosis:

 

 

 

___________________________                                        _____________

                    Signature                                                            Date

 

 

Explanation and Analysis:

As we noted in an earlier section, a comprehensive psychosocial assessment will consist of gathering information along 12 vectors, with four anchor points (the Biologic, the Psychologic, the Social and the Health Care Domains) and  three time frames (the Historical, Current Functioning, and Anticipated Needs, also called Prognosis).

By using the time frames—historical, current functioning and anticipated needs, the practitioner will gather details about strengths and challenges, what strategies were applied, how effective they were in mitigating the circumstances and what might be needed in the future to improve or avoid similar situations. The person being assessed will have the opportunity to acquire knowledge of alternative strategies or refining those strategies that were effective in similar situations in the past.

The time frames are useful in highlighting strengths and opportunities for alternative responses. This is an important element in reinforcing efficacy and confidence which contributes to the person’s ability to commit to doing things in ways that are more beneficial to successful outcomes.

Even though as a clinician you are not responsible in the management of the medical/biologic/physical aspects of the person being assessed, it is valuable information that is relevant to functional ability and demands on resources such as financial, care giver skills and potential future needs. If no medical/biologic/physical needs are identified, than this would be a source of strength for the person being assessed. Planning might include preserving and strengthening health through diet, exercise and avoiding behaviors that could contribute to acute or chronic health issues.

In the same way, psychologic/behavioral/substance use issues are important aspects of the person’s ability to handle stress and cope with challenges. These include characteristics such as ability to manage anger, cooperate with others, initiate, develop and maintain positive relationships, accurately perceive and interpret cues in the social environment, be able to communicate personal needs, make appropriate decisions about daily activity and control negative attention seeking behaviors.

Challenges in this area, could result in significant legal, financial, medical, psychiatric and functional restrictions. If no challenges are identified, than this area becomes a resource that the person can use to improve/resolve challenges identified in other domains.

The social domain relates to maintaining stable relationships, employment, satisfying leisure activities, residential stability and social supports from family or friends that contribute to a safe, stable and satisfactory quality of life. The one common factor in poor quality of life is isolation. Lack of social contacts related to family, friends, colleague or neighbors is the most obvious area of isolation. 

However, isolation can come in many forms. The paucity of leisure activity or interests can and does limit a person’s ability to problem solve, identify alternatives and reframe perceptions. It also restricts a person’s pool of social contacts and resources. As part of the psychosocial assessment, it is prudent to identify strengths and vulnerabilities in employment and residential stability. 

It is not sufficient to note that the person is employed and not homeless. The practitioner should also explore how satisfied the person is with his current state of employment and housing, what goals the person has in these areas and what challenges the person anticipates to reaching these goals. This information may lead to identification of social vulnerability that could influence the development of an intervention plan.  

The last anchor point is the health care or Systems domain. The importance of identifying the factors that influence a person’s perception of how they were treated by the system when they interact with it in times of uncertainty and confusion. 

For most of us, we expect that when things are not going well that we will be understood, supported, respected and helped.  When this does not happen, it contributes to our anxiety and level of trust in how the system can work for us. Positive experiences tend to raise our expectations and positive perceptions of the system in general.  Negative experiences tend to have the opposite effect.

These experiences could be related to financial issues such as access to services or medications, language barriers, social/cultural/religious practices that may be in conflict with the mainstream practices.  For the individual, these issues could make the difference between a successful or unsuccessful compliance, adherence and outcomes. 

Each of the four anchor points will comprise its own section, and information gathered in each of the three time frames. Many clinicians find it useful to position the clinical interventions for identified areas of focus alongside the clinical information gathered, creating a four column system. This model from our form is shown below:

 

 Historical, Current, Anticipated Needs, and Clinical Intervention 

 

Historical
Current
Anticip
Clinical Interven
 
 
 
 

 

 

In complex cases, where there is both a good deal of clinical intervention and a good deal of case management activity, it may be more helpful to place the case management activities alongside the clinical interventions, so that the entire treatment plan may be laid out together, In such instances, the addition of another column may be useful. Alternately, the current and anticipated concerns may be combined into a single column, as shown below.

 

Historical
Current /     Anticip
Case Mgmt
Clinical Interven
 
 
 
 

 

 

In complex cases, any or all of the four domains may be extensive enough to require that a full page or more be allocated to the information gathering process. For instance, a client may have multiple past and current medical conditions, each of which contributes to an understanding the client's ongoing problems with functioning, and each of which may require medical intervention, case management activities and psychotherapeutic intervention.

Because a comprehensive psychosocial assessment is likely to be read and utilized by multiple service providers, it is advisable to strive for both detail and clarity. This is to say that the information contained in the assessment should be thorough and presented in a manner that is easy to follow. In this way, all providers working with a single client or family can have a detailed overview of the complete therapeutic picture.

In order to demonstrate how this would look in real terms, below will be presented examples of different levels of problems and challenges in each of the four domains. This will include examples of case management and clinical interventions that align with the different levels of problems and challenges.

As you will note, as the level and degree of problems and challenges increase, the amount of detail is likewise increased. While it is important to be concise in the presentation of the information, no relevant information should be left out either in terms of signs and symptoms or in terms of case management activities and clinical interventions. The entire picture of the client and the interventions for the client should be laid out for easy reading.

The interventions noted in this section are suggestions and in no way represent a complete listing of possible interventions. Specific goal development is not addressed.

In each of the four areas, there will be an array of circumstances shown, from the very mild to the very serious. This will provide a general sense of how to work with this format.

For additional information on clinical and case management goal development and in depth recommendations for treatment interventions, the reader is directed to :www.practiceplanners.wiley.com . The treatment planners offered on this site cover all the elements for development of formal treatment plans including problem definitions, goals, objective, interventions and diagnosis. 

 

MEDICAL (related to physical issues only)

History
Current/   Anticip
Case Mgmt
Clinical Interv
Less  than 3 months of physical dysfunction
No symptoms OR symptoms reversible without intensive medical intervention
No action
No interventions required
More than 3 months of physical dysfunction OR several periods of less than 3 months
Mild but notable symptoms which do not interfere with current functioning
Monitor for physical limitations
 
Access treatment for previously unidentified mental health or substance use disorder
 
Establish what functions might be improved through formal rehabilitation program
 
Provide follow up and monitoring of rehab profess's recommendations regarding function with or without assistance
Explore perspective on decline in functioning with individual and family
 
Explore feelings about increased dependency and care givers
 
Help identify areas of preserved function
 
Explore alternative sources for strengthening self esteem
Confirmed diagnosis of a chronic disease
Moderate to severe symptoms that interfere with functioning
Assure active involvement of PCP and specialty care providers
 
Ongoing assessment of symptoms and/or measured outcomes over time
 
Motivate patient to comply with treatment, addressing frustration with treatment  and positive reinforce for successful sessions
Address psych components of disability such as anxiety and depression
 
Provide an opportunity for patient to discuss feeling related to care givers and care givers feelings related to patient
 
Assist patient in resolving conflicts with caregivers
Confirmed diagnosis of 2 or more chronic diseases
Severe symptoms leading to inability to function
Assess and assure treatment for all co-occurring conditions (medical, psychiatric, substance use disorders)
 
Facilitate access to all records by all treating clinicians
 
Discuss and integrate the results of all evaluations with PCP and rehab professionals as appropriate
Discuss the prognosis for recovery of function
 
Encourage discussion or questions about causes and prognosis
 
Identify substitute activities for those no longer able to be performed
 
Use reminiscence to identify and elevate life long sources of self esteem.

 

 

PSYCHOLOGIC (Related to behavior, mental health and substance use disorders)

 

History
Current/   Anticip
Case Mgmt
Clinical Interv
Able to manage stress/cooperates with medical treatment
Interested in receiving treatment and willing to actively participate
No action
Assist the person to identify barriers to success of treatment and how to minimize and/or eliminate these barriers
Mild restrictions in coping leading to patient distress and/or family or medical provider’s complaints about cooperation with treatment recommendations
Some ambivalence although willing to cooperate with treatment
Encourage counseling on coping mechanisms, stress reduction with a counselor 1-3 sessions

 

Provide education regarding symptoms and interventions
Teach relaxation techniques (deep breathing, progressive muscle relaxation, guided imagery)

 

Assist in identification of stress management techniques (prayer, walking, baking, etc) and encourage daily scheduling of these activities
 
Review healthy life style issues (diet, exercise, caffeine and nicotine consumption) and assist in developing a plan to encourage activities that contribute to general wellness.

 

 

SOCIAL (related to job, leisure, social dysfunction, residential stability, social support or social vulnerability 

 

History
Current/   Anticip
Case Mgmt
Clinical Interv
A job including housekeeping, retirement or student with leisure activities
Stable housing; fully able to maintain independent living
No action
Encourage making a formal plan for skill acquisition or skill improvement.
Monitor progress
A job including housekeeping, retirement or student with no leisure activities
Some ambivalence although willing to cooperate with treatment
Encourage counseling on coping mechanisms, stress reduction with a counselor 1-3 sessions

 

Provide education regarding symptoms and interventions
Teach relaxation techniques (deep breathing, progressive muscle relaxation, guided imagery)

 

Assist in identification of stress management techniques (prayer, walking, baking, etc) and encourage daily scheduling of these activities
 
Review healthy life style issues (diet, exercise, caffeine and nicotine consumption) and assist in developing a plan to encourage activities that contribute to general wellness.

 

 

SYSTEMS:  Language, Religious, Cultural, Health

 

History
Current/   Anticip
Case Mgmt
Clinical Interv
Full commercial / Medicare insurance; service connected veteran benefits with physical health and mental health/ substance use disorder benefits;  no trouble accessing general medical, mental health/ substance use disorder practitioners or paying for medications. No language barriers, no social, cultural or religious practices that are in conflict with the mainstream population
One treating practitioner (general medicine and/or mental health/ substance use disorder); easy access to clinic services, medications, alternative treatments
Monitor for adherence to treatment recommendations / insurance coverage and eligibility
Support patient through life style changes related to age and functional abilities

 

Reinforce acceptance of reality
Medicaid/ public assistance insurance or non-service connected veterans benefits with physical health and mental health / substance use disorder coverage; difficulty getting timely appointments for care; limited network of and/or payment to general medical and/or mental health / substance use disorder practitioners; difficulty obtaining or paying for medications. Language barriers, social, cultural and/or religious practices that are not embraced by the mainstream
Multiple treating practitioners in general medicine, and/or mental health or substance use disorders; multiple but accessible clinics with coordinated appointments;  access to translators; access to resources to purchase medications
Review correlation of disorders with treatment being given, assess barriers
 
Facilitate linkage to  resources to resolve barriers

 

Assure that there is timely record sharing and communication among providers
Explore negative or frightening aspects of dealing constructively with access to care
 
Provide comfort and support while assisting in developing problem solving strategies

 

Reinforce strategies to meet new demands, reframe the challenge as an opportunity

 

Even where great care has been taken to document a client's complete psychosocial picture, it may still be helpful to have additional sections that focus on certain aspects of a client's functioning. For example, it may be useful to have a quick checklist that examines the client's risk for suicidal and homicidal behaviors. Setting this section apart increases the likelihood that it will not be missed in a quick reading of a long and detailed document.

Likewise, other clinicians may choose to include other quick checklists from our concise assessment template, such as sections on mental status, substance abuse and domestic violence. In such instances, the more detailed explanatory text on mental status, substance abuse or domestic violence issues can be integrated into the psychologic or systems domain.

The final section of the detailed template consists of the same three components as our concise template: clinical impression, diagnosis and prognosis. As noted before, the clinical impression should consist of a concise overview of the most salient clinical issues from the preliminary gathering of information. The clinical impression allows any reader to quickly grasp which components are most important, and will direct that reader to study in more detail the relevant sections of the assessment form.

Even where a thorough and comprehensive picture of the client's functioning has been rendered, a DSM-5 diagnosis should be recorded, along with a prognosis that offers a brief summary of any obstacles or problems that may interfere with successful treatment.

While it may seem on the surface that some of these components are redundant when such care has been taken to create a thorough and comprehensive record of the client's challenges and the plan for addressing those challenges, the redundancy is an acknowledgement of how the psychosocial assessment will actually be used.

The originator of the detailed psychosocial assessment will usually be the lead clinician involved in the client's care and case management. This clinician will need to understand the client's needs, challenges and care in great detail, so that appropriate intervention can be implemented, and so referral and coordination of care can be performed with a variety of ancillary treatment providers.

However discouraging it is to ponder for the clinician who takes such care in producing a thorough psychosocial assessment, few of the ancillary providers engaged in treatment may actually read the psychosocial assessment in its entirety. Rather, they will more likely scan the assessment form for the information most relevant to their purposes, noting red flags that are raised in the sections covering clinical impression, mental status, diagnosis, prognosis, risk assessment, substance abuse and domestic violence. Red flags raised will serve as a cue to selectively examine the information more carefully in the detailed sections examining the four domains of functioning.

If the clinician has done his/her work well in preparing the psychosocial assessment, it will gather the key client information, allowing the clinician to pull together the various aspects of treatment into a unified intervention strategy. Placed in the right format, a document will be created that allows for any service provider to have access to the key information and the overall intervention strategy in a clear and easy to use manner. 

This serves the well being of the client, and allows the clinician to work with integrity and a high degree of professionalism. This completes this course on psychosocial assessment. Following the bibliography, you may continue on to the post-test section.

 

 

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