How to Write a Biopsychosocial Assessment (With Template) - Mentalyc

You're not alone if you're a therapist who feels utterly lost when writing a new client's biopsychosocial (BPS) assessment. Writing this report is more time-consuming and arguably more emotionally intimidating than other types of clinical documentation. Progress notes like GIRP or SOAP notes tend to be shorter and capture smaller time frames. Whereas BPS assessments are longer, more comprehensive in scope, and span the length of a client's life and family history.

The BPS assessment is vital to the client's chart and treatment and serves many purposes. It provides documentation of symptomology and helps determine if a client meets the criteria for a diagnosis. 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. 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.

This blog post will dive into Biopsychosocial Assessments and answer therapists' common questions. Questions like…

• What information is included in a Biopsychosocial Assessment?
• How to perfectly format a Biopsychosocial Assessment?
• How can I make this process less time-consuming?
• What Tips should I keep in mind while writing a Biopsychosocial Assessment?

By 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.

Let's get started!

What to Include in a Biopsychosocial Assessment? ( 5 Ps in biopsychosocial model)

Just like clients on your caseload, every BPS assessment is different. 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. There are specific key points you'll want to hit in every report. 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.

A common framework for writing a BPS assessment incorporates the 5 P's of case formulation (Macneil et al., 2012). The 5 P's are…

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. Documenting symptoms includes information such as symptom onset, duration, intensity, and frequency.

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. An example of this is a child whose parents are getting a divorce. The child has not shown signs of distress, but the parents are seeking treatment for the child. 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.

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. 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.

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. Therefore, It is wise to document a safety risk assessment in this section. Even if a client denies suicidal ideation or thoughts of self-harm, it is essential to note this in the response.

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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.

A comprehensive BPS assessment touches upon the following predisposing factors:

• History of previous mental health symptoms.
• History of trauma or family history of intergenerational trauma.
• Family history of medical issues, mental illness, and addiction.
• The client's medical history can include but is not limited to allergies, surgeries, head injuries, pregnancies and postpartum complications, thyroid issues, and hospitalizations.
• The client’s living situation, including who they live with, the number of dependents they care for, socioeconomic status, and any relevant information about how the client’s neighborhood impacts the client’s mental health.
• Difficulties within a client's occupation. For a child, this would mean looking at their school involvement. For an adult, this considers the client's job, work environment, financial stressors, or difficulty finding a job.

Precipitating Factors - This includes the events that have led to the client's presenting problem. Examples of precipitating factors include the loss of a job, the death of a loved one, or a car accident.

It is important to note there is no time limit on what qualifies as a precipitating factor. It is common for trauma survivors to seek psychotherapy for years, sometimes even decades, after the traumatic event. In these cases, it is advisable to document the history of trauma and any recent related occurrence that led to the client seeking treatment.

Perpetuating Factors - These are ongoing stressors in the client's life that continuously contribute to the presenting problem. This could include addiction, abusive relationships, or caretaking for a loved one with extensive medical needs.

Thoroughly assessing and documenting perpetuating factors can help a clinician provide referrals to outside resources that would support the treatment and benefit the client.

Protective Factors - Biopsychosocial assessments don't capture only the pathology and problems of a person's life. They also provide space to focus on strengths. Protective factors are the positive forces in a client's life that help moderate the presenting problem's impact or help prevent further decompensation. This might include a supportive family, a robust social network, hobbies, or a long history of success at school or work.

When the 5 P's are completed, a biopsychosocial assessment moves on to the final touches. This includes the Mental Status Exam and attaching any relevant psychological testing or outcome measures that were given. Finally, a summary, which consists of the most pertinent information from the 5 P's, is written. This summary should include details regarding safety risks and the report or observation of symptoms that would show the client meets the criteria for the diagnosis given. A diagnosis is documented, and treatment recommendations are laid out to cap off the BPS assessment.

How to format a Biopsychosocial Assessment?

There are a few formats a therapist can use for a biopsychosocial assessment. First, some organizations provide therapists with a BPS assessment form, where the clinician can fill in the blanks with thorough information. This approach creates uniformity for therapists working across the same organization. It also ensures that each area on the assessment form gets addressed, limiting the organization's liability.

Many clinicians in private practice take an approach to writing BPS assessments that more closely resembles writing a narrative. If you are a clinician taking this approach, consider using the following format from this biopsychosocial assessment example while incorporating information from the 5 Ps.

Biopsychosocial Assessment Example

Date: May 16, 2023

Client Name: Jane Nguyen

Referral Source: General Physician

DOB: April 18, 1982

• Demographics: Client is a 41-year-old Vietnamese American, married, cisgender, heterosexual female currently living with her husband of 6 years. She has three children, a son (age 6) and two daughters (age 16 and 12), who live in the home. Client reports she is employed full-time as a nonprofit attorney. Client reported she has lived in the U.S. since the age of 3, when she came to the U.S. as a refugee.

• Presenting Problem and History of Symptoms: The client reported seeking psychotherapy due to high levels of anxiety following a recent car accident. The client reported poor sleep, including nightmares and waking in the middle of the night. Stated she gets approx. 3-4 hours of interrupted sleep per night, and usually takes a sleep supplement to help her fall asleep. Client reported additional symptoms, including intrusive negative thoughts of the car accident, intense fears of another accident happening, negative self-talk, feelings of guilt, and passive suicidal ideation, including thoughts that others would be better off without her. Client reported her husband provided transportation to the assessment session and she has avoided driving since the accident occurred approximately 2 months ago. Client reported these symptoms were not present prior to the car accident although she has always had some difficulty with sleep. Client reported no alcohol or drug use.

• History of Mental Illness and Previous Mental Health Treatment: The client reported no previous history of mental health treatment. She stated she experienced low moods in her adolescence, which included a few instances of cutting behaviors to alleviate the pain she felt. The client reported no one ever knew about her cutting. The client denied history of suicide attempts. The client reported she knows she experienced some level of trauma when she was a child and her family came to the US as refugees but has no working memory of these experiences. The client reported some insight into her experience of intergenerational trauma in her family.

• Medical and Physical Health History: The client reported a history of fibroids, for which she had surgery in the past year. The client reported no other major medical issues or history of surgery. The client stated following the car accident, she received medical attention, and no long-term physical health effects were discovered.

• Family History: The client reported her husband has a history of alcohol abuse and noted he has been sober and active in AA for ten years. The client reported most likely her mother and father both suffered from trauma and depression, although it was never diagnosed or treated. She reported her mother would stay in bed for days on end, and she was often tended to by her oldest sister. The client reported cultural stigma around discussing mental health issues within her family of origin, and these concerns were never addressed openly.

• Social History: The client reported she was born into an intact family in Vietnam, and her family came to the US when she was three years old. The client reported her father worked in retail, and her mother was employed at the USPS. She stated she has two older sisters and an older brother, all of whom remain close.

The client stated she did well in college and law school and finds her work fulfilling. She reported she met her husband at a networking event for work and they dated for 10 years before getting married and having children.

She reported close relationships with friends, many of whom have children the same age as her, although has not been motivated to go out socializing since the car accident occurred.*

• Risk Assessment: The client reports passive suicidal ideation and currently contracts for safety. She denied having a plan or intent to self-harm. Stated she would never harm herself as she could not do that to her children.

• Client Strengths and Protective Factors: The client is an astute, intelligent, gainfully employed woman. She reported having a strong support system, including close relationships with her husband, friends, extended family, and her children. The client reported hobbies, including hiking, yoga, and painting.

• Summary The client is a 41-year-old Vietnamese American, married, cisgender, heterosexual female currently living with her husband of 6 years and their children. The client reported current symptoms following being in a traumatic car accident approx. 2 months ago, including difficulty sleeping, intrusive negative thoughts, negative self-talk, feelings of worthlessness and guilt, avoidance of trauma reminders, social isolation, anhedonia, and passive suicidal ideation. The client reported a history of untreated mental health symptoms in adolescence, including depressed mood and cutting behaviors, as well as a history of trauma from childhood, many of which are pre-memory. Discussed also a family history of generational trauma and depressive symptoms with no history of formal diagnosis or treatment. Client denies current intent or plan to self-harm. Expressed a sense of hope for the future.

Client’s symptoms and score on the PCL5 (43) are consistent with a diagnosis of Post-Traumatic Stress Disorder.*

• Diagnosis F43.10 Post-Traumatic Stress Disorder
• Treatment Recommendations and Referrals Recommended to attend EMDR psychotherapy 1x/week. Recommended to seek support from G.P. around her use of sleep aid.

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How can I make this process less time-consuming?

As you may have guessed by now, writing a thorough biopsychosocial assessment has historically been incredibly time-consuming. Gathering the relevant information through client meetings typically takes 1-2 hours, depending on the severity of the client's symptoms and the intensity of their experience. Meeting with collateral contacts, such as parents, teachers, and psychiatrists, can add another 1-3 hours. This doesn't even include writing the assessment! Writing the biopsychosocial assessment can add another 2-3 hours, not including the time it takes to work up the courage to open the laptop to write! The entire biopsychosocial assessment writing process done the old-fashioned way can take 3-8 hours (not including time spent procrastinating). Most therapists don't have time in their schedules for these unpaid hours of clinical documentation.

This is where AI technology comes in.

Mentalyc is an affordable, HIPAA-compliant psychotherapy note software that uses Artificial Intelligence to save therapists time. Mentalyc's easy-to-use platform listens in on client and collateral sessions, identifies relevant information, and uses this info to create a well-written biopsychosocial assessment quickly. Therapists can then review the document, make any changes, and finalize the assessment by signing and dating it. As a result, writing the BPS assessment takes a fraction of the time it used to, while the end product remains thorough and well-written. If you’re ready to save time on BPS assessment writing, register for Mentalyc.

What Tips should I keep in mind while writing a Biopsychosocial Assessment?

When writing a BSP assessment, there are a few tips to keep in mind to ensure that it is clear, objective, and effective:

• Write in the 3rd person.
• Document everything you ask about, even if the client denies it is an issue for them. If you don't document a client response, it looks like you didn't ask.
• Stay away from jargon or technical terms.
• Use clear, concise language.
• There is no one way to ask biopsychosocial assessment questions; however, therapists should pay attention to detail with follow-up questions. These include asking about symptoms' intensity, frequency, and onset or clarifying the timeline of reported experiences.
• Biopsychosocial assessment tools can include outcome measures, which are often found in the public domain for free. These tools, such as the PHQ-9 or GAD-7, help a therapist gain more information regarding the client’s experience of symptoms but cannot be used by themselves to make a diagnosis.
• Biopsychosocial assessments are used widely in the fields of social work and psychotherapy. Here is a biopsychosocial in social work example.
• To understand the client holistically, it is essential to consider their race, ethnicity, and culture in each portion of the biopsychosocial assessment.
• The assessment information should be consistent. For example, it is problematic if the last page of an evaluation includes a Substance Use Disorder diagnosis and there is no mention of the client's drinking or drug patterns anywhere on the previous pages.
• After completing the biopsychosocial assessment, a corresponding progress note should also be created for the client’s chart. In simplest terms, the progress note documents the writer’s intervention and key components of the client’s report. The assessment lays out the client’s story and symptoms in detail.

One of the most important considerations when writing a BPS assessment is to stick to the facts. This includes documenting only what behaviors you have observed or what has been reported. A therapist's opinions and value judgments do not belong in clinical documentation. AI software, such as Mentalyc, helps ensure the tone of documents is written objectively.

In conclusion, writing an effective biopsychosocial assessment is a critical component in diagnosing and treating mental health issues. Using the 5 Ps for case formulation helps us better understand our clients and the essential factors we must consider as we begin treatment. By following these guidelines and using HIPAA-compliant software like Mentalyc, mental health professionals can ensure that their biopsychosocial assessments are informative and objective.

Sources:

• Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10(111), 1–3. https://doi.org/10.1186/1741-7015-10-111

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About the author

Ann Dypiangco

Ann Dypiangco, LCSW is a mental health therapist and tech enthusiast who specializes in perinatal mental health and trauma. With a master's degree from Boston College, Ann has extensive training in psycho-sensory techniques such as EMDR and Havening. She is licensed in California and runs a small virtual practice. Ann is passionate about the intersection of technology and mental health and is excited about how AI and the metaverse will transform the industry.

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