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Psychosocial Assessment - Coggle Diagram
Psychosocial Assessment
Chief Complaint
Assessment of patient's current problems/issues
What brought them "in" today
"Can you tell me what brought you in today?"
"What are current issues/problems you are experiencing?
History of Present Illness
What may have led them to chief complaint
Present medical/psychiatric illnesses
assess when necessary: location, duration, severity, timing, context, modifying factors, and associated signs or symptoms
Do you have any current illnesses or diagnosis?
Past Psychiatric History/Psychological History
psychiatric/psychological concerns from past
"Have you ever had a psychiatric emergency where you were hospitalized?"
"Any previous medications you were on for any psychiatric diagnoses?" (ask for dose/frequency)
"Have you ever seen a therapist for any reason?"
Drug/Alcohol Assessment
assess current and past drug/alcohol use: alcohol, caffeine, heroin, opiates, marijuana, cocaine/crack, methamphetamines, inhalants, stimulants, hallucinogens, and nicotine
assess: oral, inhalation, injection, intranasal route
assess amount, frequency, and time period of use
"I'm going to assess your use of drugs and alcohol. Could you please tell me if you ever or are currently using any of the substances that I list?"
Suicidal/Homicidal Ideation
assess potential violence of individual
risk factors for suicide: attempt previous suicide, family history of mental illness, feelings of hopelessness, abusing drug or alcohol, depression of history of bipolar disorder, feelings of isolation, current diagnosis of physical illness such as cancer, aggressive behavior, impulsive behavior
risk factors for being homicidal: gang affiliation, use of drug or alcohol, psychotic symptoms, living in a high-risk neighborhood
"Have you ever had thoughts of suicide or hurting yourself?
"Have you ever previously attempted to harm yourself?"
"Have you ever harmed or physically hurt somebody else?
"Do you have a plan to commit suicide?"
"Have you had a previous suicide attempts?"
"Can you manage these thoughts of hurting others?
assess lethality of plan, means of carrying out the plan
Abuse Assessment
to assess if the patient has been harmed in anyway
"In the past year, have you been hit, kicked, or physically hurt by another person?"
'"Are you in a relationship with someone who threatens or physically harms you?"
"Have you ever been forced to have sexual contact that you were not comfortable with?"
"Have you ever been abused? If yes, describe by whom, when, and how."
Family/Social History
assesses to how the person interacts with others
those with larger support/social network are more likely to have less severe mental illness/ better chance of recovering from mental or medical illnesss
have patient describe social and support network/relationships, including their family members (siblings, spouses, significant others, children, who raised them)
assess if they have a history of being in military/has been discharged
assess for any significant life events (death of loved one, divorce, or births of children)
assess current living situation
"Where were you born? Where were you raised?"
"How many siblings do you have? How many brothers? How many sisters?"
"Can you describe to me your current social/support network?"
“What events in your life do you consider significant?”
“Can you elaborate on the events that have impacted the person you are today?”
Family History of Mental Illness
“Has any of your families ever had a psychiatric emergency or have had to go to a psychiatric facility for any reason?”
“Are there any psychiatric conditions you are aware of that your family member has?”
“Is there any history of mental illnesses in your family?”
some mental illnesses are hereditary
Common genetic mental illnesses: depression, bipolar disease, schizophrenia, and attention deficit disorder
Employment
Document patient's current employment status and occupation
Assess if it is long-term or temporary
"Do you get along well with your coworkers?"
"Do you like your job?"
"Are you experiencing any problems at work?"
"How many jobs have you had in the past 5 years?"
"Have you ever been fired from a job?"
Education
to understand the best way to interact with a patient
"What is the highest grade you completed?"
"Can you list the names of schools you have attended?"
"Did you experience any discipline problems at school?"
can provide helpful clues to patient's mental health status
Developmental History
insight into origins of patient's behavior
help to diagnose/manage current conditionsa
assess any psychological trauma they have experienced
assess patient's functioning in childhood years: friends, school, hobbies, personality
determine sexual orientation
"Please describe to me your childhood?"
"Did you make friends easily growing up?"
"Did you play any sports or in any clubs?"
“What kind of activities did you participate in when you were younger?”
Spiritual Assessment
assess patient's religious background
degree of involvement within their religious community
assess if they attend religious services
addresses if patient has unsolved spiritual needs/concerns
“Do you practice any religions?”
“For the religion you practice, do you attend church or other religious services?”
“Who do you attend religious services with?”
“Is your religion a big part of your identity?”
Cultural Assessment
assessing any critical issues regarding patient's ethnic/cultural background
examples: racism, sexism
to understand patient's beliefs, values, and practice
understand the patient's beliefs, values, and practices
”Have you faced any issues regarding your own culture or ethnicity? If so, what issues have you faced?”
“Can you tell me about cultural or ethnic issues you have experienced?”
Financial Assessment
assess the patient's financial situation
assess any major debt, employment status
lower socioeconomic class patients are at higher risk for many mental health conditions.
may need help with money and may benefit from a social worker's consultation
“What is your current financial situation? Are you financially stable? Or are you having struggles with money and managing your finances?”
“Are you in any debt? If so, how much in debt?”
"Do you manage your finances on your own? With your spouse?”
Coping Skills
“What do you typically do to relieve stress?”
“What strategies do you use when you are feeling stressed or in trouble?”
“Are you able to cope with stressful situations?”;
assess patient's current techniques, adaptive or maladaptive
“Do you think that the ways you cope are adaptive or maladaptive?”
Intrests/Abilities
assess what the patient likes to do
assess what makes patient happy/feel pleasure
"What are your hobbies?"
"What are you good at?"
"What gives you pleasure?"