Date
of Last Review 10/13/08
SME: Director of Social Services
A Social Services Clinician (SSC) makes an assessment of the patient's current
psychosocial functioning and of the patient's significant social resources/stressors.
The assessment includes a review of the patient's psychosocial development and
history. It concludes with the patient's tentative discharge plan.
The patient's current functioning and resources/stressors and psychosocial and developmental histories are explored for the following purposes:
 | To assess his/her achievement of, or failure to achieve, significant developmental milestones from birth to the present. |
| To evaluate the impact of the family of origin and any nuclear families on the patient's development and functioning |
| To assist in the elaboration of a treatment and discharge plan that will promote the patient's maximum independent functioning |
The assessment is completed as soon as possible but at least within 72 hours of the patient's admission. Pertinent information is added to the assessment as it becomes available in the course of the patient's stay.
| If the patient refuses to be interviewed or is unable to be interviewed because of the symptoms of mental illness, an attempt must be documented on the social service education section of Sunrise within 72 hours and every 72 hours thereafter until the assessment is completed or the patient is discharged. |
| When possible and permitted, the SSC contacts significant others who can provide information to complete the assessment. |
The SSC summarizes on the Multidisciplinary Problem Aggregate (MPA) any psychosocial problems that may have an impact on the patient's development and functioning in the present and on the treatment and discharge planning.
When a patient is readmitted within 6 months to UTHCPC and a complete Psychosocial Assessment had been completed during a previous admission, the SSC does the following:
| Reviews the previous assessment with the patient/family for completeness and accuracy and edits the document accordingly. Edits are placed in brackets with the date and initials of the clinician. |
| Reflects the current admission in the Presenting Problems |
| Develops a new Tentative Discharge Plan for the current admission |
| Copies the electronic report, signs and dates the report, and places it in the current record |
The following are the elements of the Psychosocial Assessment form:
| Informant |
| Problems/Stressors |
 | Admission criteria |
| Other problems impacting treatment and discharge planning |
| Developmental and Medical History |
| Psychiatric History |
| History of, or presently suicidal/homicidal ideation/gesture |
| Substance Use and Treatment History |
| Abuse History |
| Legal History |
| Family of Origin History |
| Nuclear Family History |
| Current Resources |
| Spiritual/Religious/Cultural Resources |
| Hobbies/Recreational Activities |
| Employment Status |
| Financial Resources |
| Insurance Resources |
| Citizenship Status |
| Living Arrangements |
| Preliminary Discharge Plan |
| Summary Note |
This table describes how the SSC completes the Psychosocial Assessment
Stage |
Description |
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1 |
Reviews the following:
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2 |
Interviews the following to obtain sufficient information to complete or update the assessment:
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3 |
Explains to the patient the confidentiality of the information as well as the limits of confidentiality. Informs involuntarily-admitted patient that the content and process of the interview will be made available to the Probate Court for its decision-making process. |
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4 |
Obtains written consent from the patient to involve others in the assessment, treatment, and discharge processes. |
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5 |
Enters the information obtained on the Psychosocial Assessment Flow sheet in the Sunrise Clinical Manager electronic record. Checks the appropriate options listed within each subheading and adds explanatory comments wherever possible. |
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6 |
Notes all significant psychosocial problems on the Multidisciplinary Problem Aggregate. Lists strengths on the Integrated Summary. |
Related to regulatory standards
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