How should the assessment be structured (Sample Template)

How should the assessment be structured (Sample Template)

Creating a structured template for a biopsychosocial assessment ensures that you cover all necessary aspects systematically. Here’s a comprehensive sample template to guide you through the process:

1. Identifying Information: Includes client’s name, age, gender, and contact details.
2. Presenting Problem: A brief description of the client’s primary issues or reasons for seeking assessment where client reports their concerns.
3. Biological Assessment: Document pertinent information such as personal and family health history, medications, sleep habits, physical activity, and dietary habits. Consider including results from assessments like the Patient Health Questionnaire.
4. Psychological Assessment: Include details about mental health history, emotional well-being, behavioral patterns, and thought processes. Assess cognitive functioning and note any psychiatric disorders.
5. Social Assessment: Cover aspects like environmental factors, socioeconomic status, family relationships, social support networks, and recreational activities.
6. Strengths and Resources: Highlight the client’s strengths, skills, and available resources which can aid in treatment planning. This includes coping strategies and protective factors.
7. Clinical Impressions: Summarize your observations and professional insights based on the information gathered.
8. Diagnosis: Provide any relevant clinical diagnoses or rule-outs.
9. Treatment Plan: Outline an initial treatment plan that addresses biological, psychological, and social factors, including goals, interventions, and follow-up plans for the client’s treatment

By using a standardized template like this, you can ensure your biopsychosocial assessments are comprehensive and organized, facilitating better client care and communication among healthcare professionals.

Example BPS using template above

Let us look at a biopsychosocial assessment narrative example for a client Jane Doe, 32-years old.

1. Identifying Information:  

Client Name: Jane Doe
Age: 32
Gender: Female
Occupation: Marketing Manager
Marital Status: Single 

1. Presenting Problem:  

Jane has been experiencing increasing levels of anxiety and bouts of panic attacks over the past six months. She reports difficulty concentrating at work and having trouble sleeping. She also mentions feeling socially withdrawn and avoiding activities she once enjoyed. 

1. Biological Assessment:  

Jane’s overall physical health appears stable. She maintains a balanced diet and exercises three times a week. However, she has a family history of hypertension and diabetes. Recently, she has been experiencing frequent headaches and a loss of appetite, which may be related to her high stress levels. She also notes irregular sleep patterns, averaging about 4-5 hours per night. 

1. Psychological Assessment:  

Jane has no prior history of mental health issues but is currently overwhelmed with anxiety symptoms. She reports feelings of intense worry, restlessness, and episodes of panic accompanied by palpitations. Jane struggles with negative thought patterns, including fear of failure and self-doubt. She has a history of perfectionism and high self-expectations, which exacerbate her emotional distress. 

1. Social Assessment:  

Jane lives alone in an apartment within the city. She has a stable financial situation but expresses dissatisfaction with her demanding job. Jane’s social support network includes a few close friends and her immediate family, who live out of state. Recently, she has limited her social interactions, contributing to feelings of isolation. Jane enjoys reading and hiking but has not engaged in these recreational activities due to her recent anxiety struggles. 

1. Strengths & Resources:  

Jane is highly motivated to improve her mental health. She is articulate and willing to engage in therapy. Her strong interpersonal skills and supportive relationships with her friends and family are also significant assets. Additionally, Jane’s interest in physical activities like hiking can be leveraged to enhance her well-being. 

1. Clinical Impressions:  

Jane’s symptoms are indicative of Generalized Anxiety Disorder, exacerbated by work-related stress and perfectionistic tendencies. Her avoidance of social activities and hobbies suggests a need for interventions targeted at reducing anxiety and enhancing social engagement. 

Diagnosis:  

Generalized Anxiety Disorder (GAD), ICD-10 code F41.1 

Treatment Plan:  

• Cognitive Behavioral Therapy (CBT) to address and reframe negative thought patterns.
• Mindfulness and relaxation techniques to manage anxiety symptoms.
• Sleep hygiene education to improve sleep patterns.
• Encouragement to reconnect with enjoyable activities and social circles.
• Regular follow-up sessions to monitor progress and make necessary adjustments to the treatment plan

Here’s a link to another real-world BPS example, and a downloadable template form here.