1(a)Post the completed biopsychosocial assessment for your chosen patient
1(b) Submit a paper in which you analyze the role of a biopsychosocial assessment within a healthcare setting. In your paper:
Explain how a biopsychosocial assessment can be used to affirm social work practice.
Identify at least two important aspects of this assessment that are consistent with social work values.
Explain how this assessment could help you assist other IDT members in understanding the biopsychosocial aspects of illness.
Explain how this assessment could help the IDT provide better care for the patient.
Samantha
Samantha Polaski is a 14-year-old Caucasian female who lives at home with her mother, Lauren, and her father, David.
Episode
Lauren rushed her daughter to the hospital after finding her unresponsive in her bedroom one afternoon. Samantha was stabilized in the emergency room through IV fluids and monitored further. Samantha denied taking any drugs or alcohol and reported she had been feeling “lightheaded” and “nervous” lately. After lab tests and physical examination ruled out an obvious medical cause, the ER doctor ordered a psychiatric consult. The psychiatrist recommended admission to the hospital’s behavioral health
unit. Samantha was transferred there and began treatment with an interdisciplinary
team of Dr. Turner, a psychiatrist; Tayo, a nurse; and a social worker.
Signs of Anxiety
Samantha reported a recent history of anxiety and depression, centering around the
demands of school and her social life with peers. She said she had many friends in
junior high but that since starting high school, those friends seemed to fall away.
Samantha did not participate in sports or extracurricular activities, though she admits
running on her own. In fact, she said recently she had increased her daily jogs to
multiple miles to try to address the elevated anxiety she was feeling. She stated that
running was “the only time I feel like me.”
Samantha reported one prior episode in which she temporarily lost consciousness. It
was during her first midterm exam in high school. She felt her heart quickly begin to
race and pound loudly in her ears, and she had trouble getting air. She fainted but was
able to recover quickly in the school’s health office. She reported that her peers now
“stare at me” due to this incident.
Vaccine
As part of Samantha’s stay at the hospital, nurse Tayo mentioned administering the
COVID-19 vaccine if she and the parents would like. During the conversation with the
nurse, Samantha became tearful and related how her father was against the vaccine,
fearing side effects. The night prior to Samantha’s arrival at the hospital, in fact, her
father had argued with her mother that cases for minors were mild and that Samantha
did not need a vaccine right away. He felt that the risks were unknown, and he wanted
to wait until more children were vaccinated.
Samantha reported overhearing the conversation, and while she initially wanted to get
vaccinated, her father’s comments left her frightened. So much talk about the vaccine
had left her feeling very anxious, and she could not sleep at all. This lack of sleep led to
increased anxiety on the day of the episode.
Due to Samantha’s worry surrounding the vaccine, nurse Tayo and the team decided
not to continue offering vaccination and to allow the family to work through the topic on
their own after discharge.
Care and Discharge Planning
After 2 days, the social worker discussed with the parents that Samantha was ready to
be discharged to outpatient care. David expressed that he did not want Samantha to
receive any treatment whatsoever and certainly didn’t believe she belonged in inpatient
care, whereas Lauren did not think Samantha was ready for discharge yet. “She’s safe
here,” Lauren stated. “Maybe she needs psychiatric care, David. I don’t want to find her
like that again.”
When asked what she wanted, Samantha said, “I’m just so … tired. I want to sleep.”
Consider the following questions as you take on the role of the social worker and
develop the discharge plan in Week 10:
1. What are two social aspects to consider when developing a discharge plan for
Samantha? How would you include the team in the decision-making process?
2. How would you include other team members in providing education to this
family?
3. How would you reconcile the differing opinions of Samantha’s mother and father
and also consider her needs and wishes?
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Biopsychosocial Assessment
Student Name
Walden University
SOCW 6206: Interdisciplinary Healthcare Practice
Instructor Name
Month XX, 202X
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Biopsychosocial Assessment
Name:
Date:
Agency:
Demographic Information
Age:
Ethnicity:
Marital Status:
Date of Birth:
Presenting Issue(s)
This section should include the client’s self-assessment of the problems, reasons, or
motivations for seeking treatment, as well as the onset, duration, intensity, and frequency of
precipitating stressors or symptoms (in the client’s own words).
Referral Source
State who and/or what entity referred the individual for treatment. Also specify whether
information was gathered from previous treatment records, court documents, etc.
Current Living Situation
Describe the client’s current living situation, including any of the following: others living
in the home, dependents, employment or disability status, insurance, transportation, and daily
living skills.
Birth and Developmental History
This section should include prenatal, birth, and early development history, including
information about infancy, childhood, and early adolescence. Describe family of origin—parents,
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siblings, extended family; geographic, cultural, and spiritual factors of early development; and
any history of abuse or trauma.
School and Social Relationships
This section should contain information about social development, particularly in the
context of school and peer group experiences. Include current and past friendships, educational
history (school attended, performance, education level, and extracurricular activities), and
military history (if applicable).
Family Members and Relationships
Identify family members and relationship dynamics, as well as interpersonal/marital
history. Include age of involvement in relationships, sexual orientation, length of relationships,
relationship patterns or problems, and partner’s age/occupation (if applicable).
Health and Medical Issues
This section includes medical history and current physical health, mental status, history
of psychiatric illness and previous treatment, and substance use history.
Medical History and Physical Health
State any history of traumatic injuries, chronic health problems, current illnesses, current
health status, allergies, medications and vitamins/supplements, health habits (appetite, sleep,
exercise, nicotine, alcohol, illicit drugs), sexual functioning, and risk behaviors.
Mental Status
Describe relevant observations about attitude, affect, mood, and appearance; memory,
cognition, thought process, and speech; judgment, homicidal/suicidal ideation, and
hallucinations/delusions.
History of Psychiatric Illness and Previous Treatment
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Include previous mental health diagnoses, inpatient or outpatient treatment, and history of
self-injury, suicide attempt, or suicidal ideation. Include history of aggression, violence, or
homicidal ideation.
Substance Use History
State the type of substance use, onset, duration, pattern of use, and involvement in
treatment.
Spiritual and Cultural Development
Describe the client’s spiritual beliefs and activities, including past and current
involvement in organized religion and faith-based services and programs. Record cultural
factors, such as cultural background, beliefs, and practices, that are relevant to assessment and
treatment.
Social, Community, and Recreational Activities
Record leisure activities, involvement in the community, and available social supports.
Client Strengths, Capacities, and Resources
List the client’s personal strengths and abilities, as well as available family and social resources.