Psychosocial Assessment 8/4/2020 - Coggle Diagram
Psychosocial Assessment 8/4/2020
A Chief complaint is the medical term used to describe the primary problem of the patient that led the patient to seek medical attention and of which.
Employment is asking how the patient supports themselves by asking if they are employed or not. Also to ask if they plan on staying there long term or wanted a change.
Past Psychiatric History/Psychological History-A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient
History of present illness
BACKGROUND. The history of present illness provides the initial data to generate the differential diagnoses, guide medical decision-making, investigate the patient's problem, and ultimately analyze the patient's illness
Past Medical History
is the total sum of a patient's health status prior to the presenting problem.
Past Surgical History
A history of the surgical procedures that a particular person has had, and complications therefrom, if any.
Allergies is when the immune system reacts to a foreign substance like pollen, dust, pat hair and such.
A list of medications that a given patient is currently taking
Drug and alcohol assessment helps inform a comprehensive care and management plan that meets all of the needs of the individual. It initially focuses on the cause of the presenting intoxication and secondarily aims to establish the person's drug and alcohol use frequency, level and risk
past medications the patient is, or has been on.
Suicidal Is planning to kill self and Homicial ideation is wanting to hurt others.
sexual child abuse (Rape, molestation, child pornog-
neglect (Physical neglect, educational neglect, and.
Family/Social History is medical events in the patient's family, including diseases that may be hereditary or place the patient at risk
Family History of Mental Illness may be passed on to family members for different reasons, not just genes.
Education gathering how much if the highest grade completed, how many schools have attended, and if they had discipline problems.
Current Legal Status is finding out if they had legal problems, probation, previous jail time, parole, charges pending, or has a guardian.
Developmental History-children under age 3 is an attempt to assess various aspects of the child's functioning, including areas such as cognition, communication, behavior, social interaction, motor and sensory abilities, and adaptive skills.
Spiritual Assessment is getting their religious background and if they attend any religious services
Cultural Assessment is components of culture, including environment, traditions, social relations, incentives, and values
Financial Assessment is describing the financial situation
Coping Skills is how the patient handles stressful situations
Interests and Abilities is finding out what hobbies the patient has and what their good at.
Mental Status Exam provides information for diagnosis and assessment of disorder and response to treatment