Biopsychosocial Assessment And Treatment Plan
DEMOGRAPHIC DESCRIPTION: Identify and place client in his current reality situation including age, sex, race, ethnicity, religion, nationality, marital status, social class, sexual orientation etc.
PRESENTING PROBLEM: Include problem for which client seeks help. What is the source and reason for referral; whether problem is of recent origin or a long standing issue? What is client’s perception of problem? What precipitated the referral at this time? Is this client mandated and if so, what is the client’s response to this?
APPEARANCE: Describe physical appearance and any comments client makes about his appearance. Indicate if client description seems accurate.
LEVEL OF CONSCIOUSNESS: Describe level of alertness of the client; level of distraction; ability of client to stay connected to the worker. Did client seem sleepy, lethargic, drugged?
BEHAVIOR: Include quality, tone, and rate of speech. Include statement of any unusual movement and when occurred.
MOOD AND AFFECT: Describe mood and affect of client. Were mood and affect consonant? Were they consonant with content? What is the evidence of mood and affect?
THOUGHT CONTENT AND PERCEPTION: Describe the content of the client’s thoughts and perceptions. Indicate accuracy and appropriateness of them. Indicate whether there are any indications of hallucinations, delusions, suicidal or homicidal thinking. Are there any indications of thought disturbances such as thought broadcasting, thought withdrawal, thought insertion, ideas of reference, illusions or projections?
THOUGHT PROCESS: Describe the thinking process. Indicate whether the thinking includes magical thinking, blocking, self critical thinking, tangential thinking, echolalia, clanging, circumstantial thinking, loosening of associations, nonproductive thinking or flight of ideas.
INTELLECTUAL FUNCTIONING: Describe level of abstract thing or lack of this; describe ability to calculate numbers, how distractible is the person? Indicate if there is agnosia, apraxia, dementia or concrete thinking. How much schooling has the person had?
MEMORY SPHERES: Describe short and long term memory. Indicate if there is confabulation, word finding difficulties.
ORIENTATION: Awareness of self in person, place and time.
INSIGHT: Refers to level of awareness and understanding of the illness.
JUDGMENT: Ability to make good judgments, and pragmatic choices appropriate to protecting self and others.
IMPRESSIONS AND DIAGNOSTIC STATEMENT: Include the following:
Significant personal history of client
Assessment of client’s current social functioning in immediate social situations (family relationships, work, recreation, school etc.)
Assessment of personality structure of the client with particular reference to intellectual endowment, capacity for and quality of object relationships, tolerance for frustration and capacity to delay; capacity for reality testing; discuss interplay between client’s current reality situation and his/her ability (ego strengths and weaknesses) to deal with the situation. Discuss the nature and appropriateness of his/her defense mechanism in relation to the social factors and influences of current external pressures.
Assessment of the nature of the client’s problem in light of his/her history. Tie together the significant history and factors in cause-effect relationship as understood from the history. If the history does not contain sufficient information about a specific aspect, it is important to state that this is unclear, thus pointing out areas for further exploration and assessment.
HYPOTHESIZED DIAGNOSIS, PROGNOSIS AND RECOMMENDATIONS
16. Select 2 published articles that relate to your client’s issues. Summarize them in 2 short paragraphs. Cite them is APA 6th edition format.