Please enable JavaScript.
Coggle requires JavaScript to display documents.
8-4-20 Psychosocial Assessment - Coggle Diagram
8-4-20 Psychosocial Assessment
Chief Complaint:
A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record.
Allergies
Allergies occur when your immune system reacts to a foreign substance such as pollen, bee venom or pet dander or a food that doesn't cause a reaction in most people.
Past Medical History:
Past medical history includes both your personal health history and your family health history. Past medical history information gives your doctor all kinds of important clues about what’s going on with your health, because many diseases run in families.
Drug/Alcohol Assessment
Drug & Alcohol assessment focuses on the cause of
the presenting intoxication and secondarily aims to establish the person's drug and alcohol use frequency, level and risk
Spiritual Assessment
Spiritual Assessment can help patients and nurses identify spiritual beliefs, practices, and resources, that may positively impact their health.
Past Psychiatric History/Psychological History:
Is an interview with a patient to determine past psychiatric illness.
History of present illness:
History of present illness: A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present.
Past Surgical History
Past Surgical history of the surgical procedures that a particular person has had, and complications, if any.
Current Medications
Current medications are medications that the patient is currently taking
Past Medications:
Past medications is a list of medications the patient has previously taken.
Abuse Assessment
Abuse Assessment identifies behaviors, speech, and actions of parents, caregivers, or other significant figures in a child’s life that have a negative mental impact on the child.
Family History of Mental Illness
Family history of mental illness collects lifetime family psychiatric history are useful in clinical practice and for identifying potential families for genetic studies.
Methods The Family History Screen (FHS) collects information on 15 psychiatric disorders and suicidal behavior in informants and their first-degree relatives.
Suicidal/Homicidal Ideation
Suicide assessments are informal evaluation processes psychological professionals go through to decide if the client is suicidal.
Homicidal ideation is the assessment to determine homicide risk level of danger to others.
Family/Social History
Family / Social History screening tool for identifying families with psychosocial risk profiles associated with increased risk of childhood behavioral problems.
Employment
Employment psychological assessment allows employers to determine your personality and your ability to work well with others.
Education
Educational psychology assessment involves a series of different activities to help identify a child’s or a young person’s specific learning style, strengths and areas of need.
Current Legal Status
Current legal status is the status defined by law. It is the standing of an entity, such as citizenship, and marital status.
Developmental History
A developmental and social history is an important part of an assessment for the diagnosis of learning disabilities
Cultural Assessment
A cultural assessment will help the patient and nurse to formulate a mutually acceptable, culturally responsive treatment plan.
Financial Assessment
Financial assessment evaluates as an individual’s abilities to manage or direct the management of his or her funds in a way that routinely meets the person’s basic needs of food, shelter, and clothing.
Interests and Abilities
Assessment of abilities and skills often conducted to identify occupational possibilities in which client could be successful.
Mental Status Exam
Mental Status Exam (MSE) is a psychological exam that describes the mental status and behaviors. The clinician can document objective and subjective data from the patient to determine there interest and abilities to accomplish a set goal.