How to Write a Biopsychosocial Assessment
Biopsychosocial assessments are based on the biopsychosocial model proposed by Dr. George Engel in 1977. According to Engel's model, a person's biological, social and psychological factors are all intertwined and influence their well-being. In other words, a person's body and mind are not separate entities.
For example, if a patient experiences a physical illness while lacking social support, they may become depressed or anxious. Similarly, if a person has depression, they might withdraw from their friends and family and neglect self-care, impacting their physical and social wellness.
Mental health professionals recognize the need to view clients holistically and consider how various aspects of a person's life might contribute to a mental health issue, impair the functioning or maintain a disorder.
A biopsychosocial assessment helps counselors, social workers, and other behavioral health professionals learn about their clients on multiple levels and better understand their subjective viewpoints. As a result, biopsychosocial assessments enable therapists to diagnose and effectively treat their clients.
Mental health professionals typically conduct a biopsychosocial assessment as part of the initial assessment with clients. If you would like to use biopsychosocial assessments to learn more about your clients, we have information to help you get started. In this post, we'll explore the components of a biopsychosocial assessment, questions to ask clients, and how to write a report.
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What is Included in a Biopsychosocial Assessment?
An example of the biopsychosocial model includes three components: psychological factors, biological factors, and social factors. You'll want to focus on these aspects as you gather data for your assessment via patient questionnaires and face-to-face interviews. To show you what to cover, here are descriptions of each component:
1. Biological Factors
The American Psychological Association (APA) defines biological factors as any chemical, physical, neurological, or genetic condition associated with psychological disturbances. According to the National Institute of Mental Health, many mental disorders are caused by a combination of biological, psychological, genetic, and environmental factors.
Since genes can play a part in a person's mental health and increase the risk of developing certain disorders, counselors should consider a client's family history during their initial meeting.
You might take the following information about your client into account:
- Immune response
- Environmental toxins
- Physical traumas
- Sleep/Exercise habits
Biological questions help you understand a client's medical issues and history, which can impact other areas of their life. Consider asking your client to fill out a questionnaire about their personal medical and mental health history, their family's medical and mental health history, their substance use history, and their current sleep, diet, and exercise habits.
You might ask questions such as:
- Who is your current primary care physician?
- Are you on medications, and if so, what are they?
- Are you allergic to any medications?
- Do you have a personal or family history of substance abuse or mental health disorders?
- Are you experiencing any medical problems that are impacting your life?
- What medical or surgical issues have you had in the past?
2. Psychological Factors
Psychological factors refer to a person's thought processes and how they influence mental states and behavior. Psychological factors can impact a person's physical well-being and vice versa.
For example, according to a review published in Neural Plasticity, up to 85% of patients with chronic pain experience severe depression. As the researchers state, chronic pain and depression are closely correlated, and one disorder affects the other's progress.
To understand your clients better, consider psychological factors and related information, such as:
- Psychological traumas
- Coping skills
- Suicidal ideation
- Reaction to illness
The psychological component of a biopsychosocial assessment aims to paint a picture of a person's thoughts, feelings, behaviors, and overall mental state. To identify psychological factors that may be influencing your client's health, you can give them a questionnaire containing a current symptom checklist and a checklist of emotional and behavioral issues.
You might also ask the following questions:
- What brings you in today, and how long have you been experiencing this problem?
- How would you describe yourself?
- What are your strengths and weaknesses?
- Have you had counseling in the past?
- Have you had suicidal or homicidal thoughts?
- What do you feel is your greatest need right now?
- What do you hope to gain from therapy?
3. Social Factors
The APA defines social factors as aspects that "affect thought or behavior in social contexts." According to a review published in Current Psychiatry Reports, social determinants, such as income level and familial relationships, can significantly impact mental health.
For example, according to the review, studies show a correlation between poor mental health and lower incomes. Also, emotional support is considered a protective factor against common mental health disorders.
To learn about a client's social circumstances and how these factors influence their mental and physical health, you might focus on the following:
- Family relationships
- Social support
- Marital status
- Cultural influences
- Living situation
- Military service
- Spiritual or religious background
- Hobbies and recreational activities
- Financial status
- Sexual history
- Legal history
- Educational background
- Employment status and work history
Ask questions that help you understand your client's past and current relationships, work-related stressors, finances and involvement in their community. You might ask:
- Are you involved with any community organizations?
- Who is in your family?
- Are there any problems in your family now, or were there issues in the past?
- How much support do you expect from family members?
- Do you have close friends?
- Are there any issues with your friendships?
- Who can you rely on for support?
- Have you ever been arrested?
- Were you ever sentenced for a crime?
- What kind of work do you do, and what have you done in the past?
- How much work-related stress is in your life?
- Have you ever served in the military?
Write Better Biopsychosocial Assessments
In this webinar, we review the history of present illness, past psychiatric history, medical history, social history, and family history. We review how to properly document level of care justification for payor sources. Finally, we cover how using an electronic medical record system to document mental health treatment can improve efficiency, allowing practitioners to devote their time and attention to individuals who need their assistance.
How to Write a Biopsychosocial Assessment
as a Mental Health Professional
After you've gathered data about your client, you can write a biopsychosocial assessment report. Your report will help you understand your client as a whole individual to devise an effective treatment plan. You can also share your assessment with colleagues or physicians to coordinate care.
Here's a biopsychosocial assessment outline to help you get started:
Begin your report with basic information about your client. This should include:
- Identifying information: Include identifying information such as your client's name, gender, date of birth, and marital status.
- Referral: Provide the name of the person or agency who referred the client to you, and include the type of assistance they sought.
- Presenting problem: Describe the reason the client came to you. Include the client's definition of their problem, how long they've been experiencing the issue and what they expect to gain from your services. Also, describe what the client has done in the past to try to resolve the issue.
- Source of data: List everything you used to gather data for your reports, such as questionnaires, interviews, observations, test results, and records from the referring agency. Describe your client's involvement in compiling the information.
- General description of the client: Briefly describe your client's appearance, mood, and level of cooperation during the interview. List any problems the client has with memory, thinking or speech, and signs of anxiety, depression, or other mental health issues.
Client's History and Current Functioning
Examine the client's history and current functioning and include relevant details. Address the following areas when writing your report:
- Family history: Describe the client's family members, including details about the client's childhood relationships and who they grew up with. List family members' history of substance abuse, legal problems, or psychiatric disorders.
- Educational background: Write about your client's educational experience, challenges they may have faced, and current goals.
- Employment status and history: Include your client's current employment status and occupation, an overview of their work history, and any special skills or training they have.
- Religious or spiritual beliefs and practices: Mention if your client identifies with a religion or spiritual beliefs. Include any involvement they may have with a religious community.
- Military service and history: Mention if your client was or wasn't in the military. If they served in the military, describe their role, the dates they served, any highly stressful experiences they had, and the type of discharge they received.
- Current and past medical background: Describe your client's current general health and functioning. Mention any history of disease, accidents, and medication. Consider their family's medical history.
- Mental health history: Describe your client's mental health history. Mention any history of abuse, violence, or neglect.
- History of substance abuse: Include your client's substance abuse background, if any. List current and past experiences, such as when they started using drugs or alcohol, and how much they used. Include any treatment they received.
- Social and recreational activities: Describe your client's social network, including significant relationships. Mention if your client is involved in the community or has hobbies.
- Basic life functioning: Add your client's current functioning level and if they can meet their basic life needs, such as obtaining housing and food. Write if they require assistance.
- Present legal concerns or past issues: Include any legal concerns your client has or dealt with in the past, including marital issues or domestic violence.
- Client's strengths and resources: Evaluate how your client copes with issues. Mention their strengths and limitations.
- Other environmental or psychosocial factors: Describe other factors that may influence your client's mental health, such as discrimination or sexuality issues.
Your Assessment and Recommendations
After you provide an overview of your client's current and past psychological, biological and social states, it's time to include your professional assessment. You might offer the following information:
- Brief summary: In about three to five sentences, summarize what you've already written in your report. Your biopsychosocial summary should include the primary problem your client has and the contributing factors. Describe your client's level of urgency regarding the problem. Mention any secondary issues or concerns your client shared.
- Client's appearance: Describe how your client appeared during the interview, including signs of anxiety or depression and any memory or speech issues.If you also conducted a mental status exam during your initial meeting with a client, include it in this section.
- Your impression: Provide your impression of the client and their current state and how they are handling the presenting problem. Discuss your assessment of the client's motivation to use your service and change harmful behaviors.
- Diagnosis: Include your diagnosis and any diagnoses your client claimed they'd been given in the past by other therapists.
- Goals and recommendations: Identify long-term and short-term goals. Describe the type of treatment you think is best for your client and any suggestions for services and resources. Also, include how long you think your client should receive treatment.
Tips to Remember When Writing a Biopsychosocial Assessment
As you write your biopsychosocial assessment report, it's important to consider who will use your assessment to provide care. Here are tips to help communicate your assessment with colleagues and other care providers:
- Differentiate between objective facts and subjective impressions: Make sure to frame information in a way that separates facts from your impressions. Objective facts include things the client actually said, and subjective impressions include how the client appeared to you. Be sure to clarify who said, thought or did something in your report. For example, to have an objective fact, you might write, "The client said he felt sad when he lost his mother." To state a subjective impression, you might write, "The client seemed sad when he talked about his mother."
- Create a balance of information: The point of a biopsychosocial assessment is to illuminate the presenting problem and help you understand your client. To achieve a useful evaluation, make sure your report includes a balanced mix of helpful information such as the client's strengths and challenges, facts and impressions, and data from various sources, if possible.
- Present information based on priority: Decide which problems are most important and need urgent attention, and spend more time writing about these issues in your report. You'll also want to present the primary issues first.
- Consider accuracy: Other physicians or therapists may read your report, so it's crucial to be as accurate as possible. Ensure you accurately convey what the client or other sources said or did and remove or rewrite errors or misleading information.
- Remove irrelevant details: You do not need to include everything the client said, thought, felt or did in your report. Instead, aim to include only relevant information. Overall, you should organize the report in a logical manner that's easy to read and comprehend.
Using Technology to Reduce Your Documentation Burden
Writing a biopsychosocial assessment is just part of your documentation workload as a behavioral health professional. In addition to evaluations, you likely have progress notes, psychotherapy notes, treatment plans, medical records, privacy notices, and consent forms to complete, organize and keep secure. Although these documents enable you to treat clients and provide the best care possible, they can also be time-consuming if you don't use document management tools.
If you need assistance managing documentation in your practice, ICANotes electronic health record (EHR) software for behavioral health can reduce the amount of time you spend writing, organizing, and searching for critical documents. ICANotes was designed by a clinical psychiatrist for behavioral health professionals and is a comprehensive EHR system. With ICANotes, you can:
- Scan forms or questionnaires to keep digital files.
- Quickly and securely access clients' records from your phone, tablet, or laptop.
- Keep all records, forms, and notes organized and compliant with privacy laws.
- Take advantage of customizable templates and automatic data population to reduce documentation time.
- Ensure accurate, legible notes to enable better care coordination and faster reimbursement.
- Keep clients engaged and satisfied with the convenient patient portal.
Overall, ICANotes can help you run an efficient practice and allow you more time to focus on your clients.
Try ICANotes for Free
If you would like to create initial assessments, progress notes, and treatment plans in a secure, intuitive behavioral health EHR system, request your free trial and experience ICANotes today.
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