Family history of medical issues, mental illness, and addiction.History of trauma or family history of intergenerational trauma.History of previous mental health symptoms.Predisposing Factors - These factors in a client's life contribute to the presenting problem and can include genetic, biological, or environmental influences and past childhood experiences.Ī comprehensive BPS assessment touches upon the following predisposing factors: Even if a client denies suicidal ideation or thoughts of self-harm, it is essential to note this in the response. Therefore, It is wise to document a safety risk assessment in this section. The biopsychosocial assessment may serve as legal protection to the therapist in a case where the client goes on to cause harm to themselves or others. In these cases, it is advisable to seek information from reliable outside sources, such as parents, psychiatrists, or hospital discharge paperwork, to include in the BSP assessment. Some clients are not attuned to the risk or impairment caused by their symptoms or cannot give an accurate report due to their developmental level or severe symptomology. They know the divorce will create upheaval in the child's life and want to be proactive by providing a safe, objective third party for the child to share their feelings with. The child has not shown signs of distress, but the parents are seeking treatment for the child. An example of this is a child whose parents are getting a divorce. The presenting problem can also include life stressors that a client faces that put them at risk for future impairment, even if they are not currently experiencing mental health symptoms.
Documenting symptoms includes information such as symptom onset, duration, intensity, and frequency. Presenting Problem - This is the primary complaint or reason the client has come to treatment in the first place and typically means describing what mental health symptoms they are experiencing. Additionally, if you're working for an agency or writing the BPS assessment as part of a legal proceeding, confirm if specific requirements must be included to be accepted by the involved institutions.Ī common framework for writing a BPS assessment incorporates the 5 P's of case formulation (Macneil et al., 2012). There are specific key points you'll want to hit in every report. As you may have guessed from the document's name, the biopsychosocial assessment includes evaluating the client’s biological, psychological, and social aspects of life. Just like clients on your caseload, every BPS assessment is different. What to Include in a Biopsychosocial Assessment? ( 5 Ps in biopsychosocial model) What Tips should I keep in mind while writing a Biopsychosocial Assessment?īy the end of this blog post, you'll feel less overwhelmed, be secure in your understanding of how HIPAA-compliant technology can make this process much easier, and be ready to dive into the world of biopsychosocial assessment writing.How can I make this process less time-consuming?.How to perfectly format a Biopsychosocial Assessment?.What information is included in a Biopsychosocial Assessment?.This blog post will dive into Biopsychosocial Assessments and answer therapists' common questions. Given that the BPS assessment is the most lengthy and comprehensive piece of documentation in a client's chart, it is the document most likely to be read by other service providers, such as psychiatrists and future therapists, to inform their care. It also lays out a detailed understanding of an individual's physical, psychological, and social aspects, which helps a clinician develop a holistic case formulation and targeted treatment plan. It provides documentation of symptomology and helps determine if a client meets the criteria for a diagnosis. The BPS assessment is vital to the client's chart and treatment and serves many purposes. Whereas BPS assessments are longer, more comprehensive in scope, and span the length of a client's life and family history. Progress notes like GIRP or SOAP notes tend to be shorter and capture smaller time frames. Writing this report is more time-consuming and arguably more emotionally intimidating than other types of clinical documentation. You're not alone if you're a therapist who feels utterly lost when writing a new client's biopsychosocial (BPS) assessment.