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…
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!
✅ SOAP, DAP, EMDR, Intake notes and more
✅ Individual, Couple, Child, Family therapy types
✅ Recording, Dictation, Text & Upload Inputs
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.
