Download Biopsychosocial Clinical Interview

Cumberland Heights Foundation, Inc.
POLICY MANUAL
Subject:
Biopsychosocial Assessment
Effective Date: 2/1/94
Initiated By: Cinde Stewart Freeman
Chief Quality Officer
Approved By: James B. Moore
Chief Executive Officer
Review Dates: 2/97, 3/10 CB/DF
02/11 Committee, 2/14 Committee,
2/14 Committee, 4/15 Committee
Revision Dates: 12/10/98 CSF
2/19/02 CSF 12/02 CSF, 03/12 DK,
04/12 DNF, 7/13 WRPC, 2/14 CH
POLICY:
Patients admitted to a Cumberland Heights treatment program shall receive a
comprehensive biopsychosocial assessment to determine the clinical needs of the patient
and facilitate an individualized plan of care.
PROCEDURE:
1. The following information shall be gathered during the intake and/or admission process
by an admissions staff member:
• Demographics
• Precipitating event
2. Residential Programs
A comprehensive biopsychosocial assessment shall be completed by a qualified staff
member within 5 business days of admission.
A biopsychosocial assessment update is permitted on any patient re-admitted within
60 days of most recent discharge. After 60 days a new biopsychosocial assessment
shall be completed.
Outpatient Programs
A comprehensive biopsychosocial assessment shall be completed by a qualified staff
member no later than session seven (7). A biopsychosocial update will be completed on
any patient transferring from the residential programs to be entered into the chart no
later than session five (5). It will include updates pertinent to information that has
changed since leaving the residential program including but not limited to: obstacles to
recovery, summary evaluation, and treatment recommendation.
3. It is the responsibility of the Counselor to ensure completion of the biopsychosocial
(BPS) clinical interview
4. The biopsychosocial clinical interview includes review of the initial chemical
dependency assessment in the following areas:
a) Demographics
b) Presenting Problem, reason for current admission;
c) History of Substance Use, including previous treatment, symptomatology,
motivation for treatment, and perception of the severity of the chemical use
problem;
(continued)
Biopsychosocial Interview
Page 2 of 2
d) Medical History, physical health patterns, including medical problems, medications,
pain, nutrition, weight and body image, sleep patterns, and alcohol/drug related
accidents;
e) Emotional/Behavioral, self-concept/psychological functioning, including coping
mechanisms, history of violence/depression/ suicidal ideations, previous psychiatric
history, and family history of mental illness;
f) Family/Living Environment, current family/relationships, including the current
home environment, any chemical use in the home, and current intimate
relationships/children issues for adult;
g) Family History, family of origin issues, including history of addiction and traumatic
events (the legal custody status of adolescents is also confirmed);
h) Childhood/Adolescent History, developmental history and the impact of addiction
on this, as well as the impact of the family on the addictive dynamics and the
impact of the addiction on the family;
i) Sexual History, including orientation, sexual abuse history as either victim or
perpetrator, and significant relationships;
j) Social Relationships includes peer groups, patterns of interaction, bonding, etc.
k) Religion/Spiritual, religious preference, belief systems, and values.
l) Cultural/Ethnic, values and beliefs, including perceptions of gender, alcoholics, drug
addicts;
m) Military, assessment of combat status if in military;
n) Leisure/Recreational, social patterns, including hobbies, special skills, daily
activities,
o) Education/vocational/employment/financial, including grade history, literacy,
learning disability status, (for adolescents, school conflicts and use at school),
current employment and issues, career goals, impact of chemical use on finances,
and;
p) Legal, including arrests, current or pending charges, associations with
probation/parole officers or attorneys;
q) Patient/Family Goals, what do they want to work on, how do they want together to
accomplish these goals;
r) Obstacles to Recovery such as co-occurring disorders, high risk jobs, life passages,
language difficulty.
s) Summary to include things that set patient up for substance abuse, obstacles to
recovery, strengths, and motivations.
t) Treatment Recommendations, what will be done to address pre-disposed factors,
major life consequences of addiction, obstacles, motivations, and strengths.
5. The BPS clinical interview, in conjunction with the initial CD assessment and the
assessments of the other disciplines forms is then used by the counselor and patient for
the development of an individualized plan of care.
6. These initial findings are presented to the treatment team at the first Treatment Plan
Review (see related policies).