Psychosocial Assessment Guide

Paper details:

from those three files develop a biopsychosocial assessment guide to include a mental status exam, substance use/abuse and trauma history.

PSYCHOSOCIAL ASSESSMENT

I. Identifying Information
A. Reason from referral
B. Referral source
C. Age
D. Ethnicity, religion
E. Marital status
F. Presenting problem and duration

II. Previous level of functioning (i.e., prior to hospitalization and/or social work assessment.)
A. How medical status impacts level of functioning – ADL status
B. Work, school, etc.

III. Support Systems
A. Family constellation and/or significant others
B. Community supports (individuals and agencies)

IV. Financial Status
A. Entitlements an/or eligibility
V. Relevant past history
VI. Assessment
A. Mental status
B. Problems/needs as perceived by patient and worker
C. How these problems are understood/accounted for based on information obtained

VII. Plan
A. Follow-up by Beth Israel Deaconess Medical Center social work
B. Referrals to other providers/agencies
s:social workwordweb_site_formsjcaho 04psycho.doc 4/14/09
Mental Status Exam
History: See health history
Physical exam
Appearance: more than NAD, more than grooming; relaxed/anxious, eye contact, attitude toward examiner
Speech/Language: spontaneous, hesitant, clear, garbled
Affect: appropriate, pleasant, angry, flat
Content of thought: hallucinations (visual/auditory)
Thought process: irrelevant, flight of ideas, racing, tangential thoughts, circumstantial thoughts
Cogniton:
Orientation
Memory
Knowledge of current events/ general fund of knowledge
Abstraction
Calculation
Emotional response
Judgement
Object Recognition (gnosia)
Voluntary Movement (praxis)

MMSE
Orientation
Registration
Attention and calculation
Recall
Language

***Social History
• Education and future plans (addressed in health maintenance/promotion or social history)
• Occupation (addressed in health maintenance/promotion or social history)
• Safety (addressed in health maintenance/promotion or social history)
Suicidal/homicidal ideation (addressed in the “neuropsych section of our HH”;
• Family relationships and home life (addressed in health maintenance/promotion or social history)
• Spirituality (addressed in social history, health maintenance/promotion)
• Social support (addressed in health maintenance/promotion or social history)
• Stress, coping, and sleep (addressed in health maintenance/promotion or social history)
• Depression, anxiety (addressed in psych history)
• Alcohol and alcoholism (addressed in health maintenance/promotion or social history)
• Drug use (addressed in social history, health maintenance/promotion)
• Tobacco and secondhand smoke (addressed in social history, health maintenance/promotion)
• Exercise, media time, and activity (health maintenance/promotion)
• Diet and caffeine intake (addressed in social history, health maintenance/promotion)
• Sexuality patterns (addressed in social history, and “Genital” section of HH)
• Feelings about food and weight (not addressed previously)
• Bullying ( not addressed previously)
Examples:

Dress and grooming appropriate, speech fluent, affect and responses appropriate to situation, oriented x 3. Cooperative, no agitation, recent and remote memory intact, no hallucinations. No difficulty with serial 7’s or attention. Able to follow simple written commands. Abstract thought intact, judgement appropriate; no agnosia or apraxis.
Dress and grooming appropriate, appears anxious, speech hesitant, flat affect., disoriented, but cooperative, unable to recall 3 objects, remote memory intact, no hallucinations. Unable to complete serial 7’s. Able to follow simple written commands. Unable to correctly interpret abstract thought) judgement appropriate; no agnosia or apraxis.