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A Guide for Writing Psychosocial Reports

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Date of report: Date report is written Date of interview: (if different from date report is written) Guideline Questions Step One Source of referral: ... – PowerPoint PPT presentation

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Title: A Guide for Writing Psychosocial Reports


1
A Guide for Writing Psychosocial Reports
  • SW 550
  • Field Practicum I

2
Rationale
  • Psychosocial reports
  • Provide an in-depth view of the clients life and
    how the client and others see him or her as
    functioning
  • Are used by the courts, hospitals, schools,
    social service and mental health agencies, and by
    other professionals to make crucial decisions
    about peoples lives and the direction these
    lives may take

3
Rationale
  • Serve as the foundation for providing accurate
    assessments and effective interventions
  • Dynamically respond to changes in the clients
    life circumstances
  • Demonstrate accountability for professional
    services
  • Provide required documentation for agency
    personnel, legal and regulatory bodies, and
    funding sources
  • Serve as a method to evaluate practice outcomes

4
Analogous terms used
  • Social assessment report
  • Biopsychosocial assessment
  • Social history
  • Psychosocial study
  • Biopsychosocial-spiritual assessment

5
Varied Formats
  • Formatting of the psychosocial report varies
    depending on the agency setting and the needs of
    the clients served
  • Common elements include multidimensional focus on
    the interaction of human biological,
    psychological, and social functioning

6
Pointers
  • Psychosocial reports should be
  • Concise
  • Organized
  • Objective
  • Factual
  • Thorough
  • Neat

7
Pointers
  • Use correct syntax, spelling and grammar
  • Write in the third person singular
  • Avoid subjective language or obvious personal
    opinions and biases
  • Submit report in a timely manner
  • Safeguard confidentiality
  • Exclude irrelevant information

8
Pointers
  • Report should refer to clients by title and last
    name unless client is a minor
  • Final report may not be altered after it becomes
    part of the clients file, but a re-assessment
    report or an addendum can be submitted to correct
    factual errors

9
Multi-Dimensional Client Information Included in
Report
  • Biological dimension
  • Psychological/emotional dimension
  • Family dimension
  • Religious/spiritual dimension
  • Social/environmental dimension (micro and macro
    dimensions)

10
Suggested Format Outline Step One
  • Initial
  • Report heading
  • Date of report
  • Name of client
  • Source of referral
  • Source of information
  • Reason for referral

11
Guideline Questions Step One
  • Report heading Name of agency
  • Name of Client This should be at the top of the
    report under Report Heading and usually listed
    with the last name first.
  • Date of report Date report is written
  • Date of interview (if different from date report
    is written)

12
Guideline Questions Step One
  • Source of referral Who referred the client?
    Could be self-referred or referent(s) may be
    listed by occupation with or without specific
    names (i.e. teacher, neighbor, parent, doctor)

13
Guideline Questions Step One
  • Source of Information Where and from whom did
    you obtain information from this interview? The
    client? The doctor who referred? The relative,
    friend, neighbor, teacher? The previous case
    file or chart?

14
Guideline Questions Step One
  • Reason for referral Be as specific as possible
    about why the referral was made. This should be
    brief and concise. You will expand on this under
    problem description.

15
Format Outline Step Two
  • Background Information
  • Client demographics
  • Behavioral observations of client
  • Problem description

16
Guideline Questions Step Two
  • Client demographics What is the age, sex,
    marital status, and race of the client? What and
    where is the clients current living arrangement?
    With whom is the client currently living?
    Identify the age and relationship of current
    family members in the household. How long has
    client lived in current housing?

17
Guideline Questions Step Two
  • Behavioral observation Did the client arrive on
    time for the appointment? Was he or she
    accompanied by anyone? How was his or her
    hygiene and physical appearance? Did the client
    exhibit any behavioral, cognitive, physical, or
    emotional problems?

18
Guideline Questions Step Two
  • Problem Description Expand on reasons for
    referral based on information gathered during the
    interview.

19
Format Outline Step Three
  • Multi-system review (history and current)
    biological, psychological, family,
    religious/spiritual, social/environmental (micro
    and macro)

20
Guideline Questions Step Three
  • Biological/Developmental/Medical Does the
    client and/or immediate family members have any
    significant physical problems? Inquire about
    appetite and sleep as disturbances may be
    indicators of problems such as depression,
    stress, food insecurity, etc. If relevant, such
    as with children, inquire about developmental
    history (Did child meet his developmental
    milestones appropriately?) Also be sure to
    inquire about substance use patterns, including
    tobacco, alcohol (ETOH) and other drugs, both
    illicit and prescribed. If there is use of
    substances, document type, frequency, amount and
    impact on clients life. Are there problems with
    access to medical care, medications, and/or
    health insurance?

21
Guideline Questions Step Three
  • Psychological Is there any family history of
    anxiety, mood disorders, thought disorders, or
    behavior problems? Any psychiatric admissions or
    outpatient treatment? If there is a positive
    history of depression, inquire about suicide
    history.

22
Guideline Questions Step Three
  • Family (Immediate household members, including
    relatives and non-relatives, should already have
    been identified earlier in report.) Does the
    client have any relatives nearby? What is the
    nature of significant familial relationships? Is
    the client involved in other significant
    relationships? Are there problems related to
    domestic violence, current or past? Adverse
    family conditions, such as incarcerations,
    traumatic events, etc.?

23
Guideline Questions Step Three
  • Spiritual/Religious What are the clients
    current or past religious affiliations or
    beliefs? How does the client perceive and give
    meaning to the events of his/her life?

24
Guideline Questions Step Three
  • Social/Environmental Describe relevant aspects
    of the clients local community. What are
    relevant cultural and socioeconomic factors?
    Legal issues? Issues related to housing, food,
    transportation, utilities, telephone? Does the
    client have adequate resources to meet his/her
    needs? What are the macro issues that influence
    the client? What relevant local, state, or
    national laws apply? Stereotypes or environmental
    hazards? Available resources?

25
Format Outline Step Four
  • Assessment
  • Concise statement summarizing the significant
    findings of the report and relevant features of
    the clients psychosocial functioning, including
    problems and strengths
  • Use of psychiatric classification (DSM IV-TR) may
    be used but does not replace the psychosocial
    assessment

26
Guideline Questions Step Four
  • Assessment What is your impression of the
    clients situation? What are the chief problems
    or concerns? What strengths or resources do you
    identify? Are there any safety concerns that
    require attention? How motivated is the client
    to receive services? What are the chief
    obstacles? Are there any macro-system issues that
    can be addressed? What general direction should
    intervention take?

27
Format Outline Step Five
  • Plan
  • Specify concrete actions to be taken by client(s)
    and/or social worker
  • Address the problems and strengths identified in
    the report
  • Address immediate needs first

28
Guideline Questions Step Five
  • Plan Identify your actions, the clients
    actions, and your recommendations based on your
    assessment. Start with the most pressing concern.
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