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08/04/2020 Psychosocial Assessment A.P - Coggle Diagram
08/04/2020 Psychosocial Assessment A.P
Chief Complaint
Medical term to describe the problem that led the patient to seek medical attention.
Family/Social History
Assessment done to find out the patients family, how many siblings, if they have any children.
Spiritual Assessment
This assessment is to find out if the patient is spiritual or has any religious background, and attends religious services.
Past Surgical History
The medical history, case history, or anamnesis of a patient is information gained by a physician by asking specific questions
Coping Skills
How does a patient cope in a stressful situation.
Current Legal Status
This assessment is to find out if the patient has had any legal problems, any jail time, pending chargers, and parole.
Past Medical History
Is the total sum of a patient's health status prior to the presenting problem.
Drug/Alcohol Assessment
This assessment helps inform if a patient has taken any drug or alcohol in the past, present or if they are at risk for it.
Mental Status Exam
This exam is provides information about the patients mental status.
Employment
This assessment is gathered to find out the patients employment status, how long they have been at the job, if they have been fired from the job.
History of Present Illness
The background of the illness which help diagnoses medical decision making.
Abuse Assessment
Has the patient ever been abused, physically, sexually, emotionally, or mentally.
Allergies
When the immune system reacts to a foreign substance.
Developmental History
This question asked to a patient reveles about their childhood and any painful and traumatic experiences they had.
Financial Assessment
This assessment is asked for the patient to describe the financial situation.
Past Medications
List of medications the patient has taken in the past.
Current Medications
List of medications the patient is taking.
Cultural Assessment
This assessment is to find if the patient has any cultural background or any issues with culture.
Education
Gathering about the patients education, highest grade completed, how many schools attended, and discipline problems.
Interests and Abilities
What is the patient's interests and hobbies
Suicidal/ Homicidal Ideation
Suicide and homicidal ideation is does the patient think about harming them self or others.
Past Psychiatric history
Acquiring a psychiatric history follows the same format as any medical history, with particular emphasis on development and social factors.
Family History of Mental Illness
Family history of mental illness is does anyone else in the family have an mental illness.