ABSTRACT
A complete biopsychosocial assessment includes the following items:
Identifying data, including the patient’s name, age, sex, ethnicity, marital status, sexual orientation, and employment and living situations
The chief complaint, in the patient’s own words
A history of the present illness, including symptoms relevant to the chief complaint looking toward DSM-IV classification and differential diagnosis, duration, precipitants and mitigants, and a review of systems to rule in or out the major mental illnesses (delirium, psychiatric disorder due to a general medical condition, substance use disorders, dementia, bipolar disorder, primary psychotic disorders, major depression, and anxiety disorders)
Allergies
Medications
Past medical history, including information on alcohol and drug use, nicotine, and caffeine
Past psychiatric history, including previous treatment episodes, medication history, hospitalizations, suicide attempts or violence, and psychotherapy
Family history for structure and medical and/or psychiatric illnesses
Social history, including developmental history, psychodynamic factors, physical or sexual abuse, education, military service, employment history, legal history, sexual or marital situation, religious beliefs, support system, and stressors
A physical examination, if any, typically limited to a neurological examination, but may include any general physical examination as required
A mental status examination, including general appearance, behavior, interaction, speech, mood (subjective emotional state), affect (external expression of mood), thought process (organization), thought content (suicidal or homicidal, hallucinations, and delusions), formal cognitive testing (level of consciousness, orientation, recent and remote memory, attention, language, praxis, naming, and abstraction), judgment, and insight
Laboratory data
DSM-IV diagnoses:
|
Axis I: |
Psychiatric Diagnoses except Personality Disorders |
|
Axis II: |
Personality Disorders/Mental Retardation |
|
Axis III: |
Medical Disorders |
|
Axis IV: |
Current Stressors, none to catastrophic |
|
Axis V: |
Current and Remote Functioning, 1–100 scale |
Biopsychosocial formulation
Biological contributors to DSM diagnosis, genetic contributions, medical and substance use contributors
Psychological/psychodynamic formulation (drive, ego, object, self) and cognitive-behavioral formulation
Social structure deficits and stressors
Plan addressing biological, psychological, and social factors
(Five axis diagnostic categories used with permission from the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition. Copyright 1994, American Psychiatric Association.)
