A psychosocial assessment is an evaluation of an individual’s mental health and social well-being. We assess self-perception and the individual’s ability to function in the community. The goal is to understand the patient to provide the best care possible and help the individual obtain optimal health.
The psychosocial assessment helps us determine if the patient is in mental health or a mental illness state. Mental health is a state of well-being where one can deal with the typical stresses of life, work productively, and contribute to their community.
Mental illness is a pattern of behaviors troubling the person or the community where the individual lives. Mental illness may modify reality, influence daily living, or harm judgment. Mentally ill individuals often have a reduced ability to cope with society, maladaptive behaviors, and a reduced ability to function.
The first step in assessment is to identify the patient. A patient’s identity includes name, gender, birth date or age, marital status, race, ethnicity, and language. The chief complaint is the main reason the patient is presenting, in their own words. The history of the present illness is a chronological account of what led up to the chief complaint. This section may include the problem’s location, duration, severity, timing, context, modifying factors, and associated signs or symptoms.
Psychiatric and psychological history is the history of all psychiatric or psychological concerns in the past. The medical or surgical history includes listing all medical illnesses, surgeries, and dates. All current and past medications are listed, including the dose and frequency. A listing of who prescribed and why they are prescribed are documented for medications currently taken. A listing of why they were started and stopped is also documented for past prescribed medications.
A history of alcohol and drug use is essential in the psychosocial assessment. The substances currently used are documented, including the method of use (oral, inhalation, injection, intranasal), the amount, the frequency, and the time. Any substances used in the past are also documented. Common abuse substances include alcohol, heroin, opiates, marijuana, cocaine, crack, methamphetamines, inhalants, stimulants, hallucinogens, caffeine, and nicotine.
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