Comprehensive Biopsychosocial Assessment Notes

Sunrise Health Clinic 123 Wellness Way Springfield, SP 12345 Date of Exam: 11/01/2024 Time of Exam: 10:30:00 AM Patient Name: John Doe Patient Number: 987654321 Biopsychosocial Assessment History: John Doe is a 45-year-old male, Caucasian, married, and a resident of Springfield. He states, "I feel overwhelmed and anxious all the time." The information on his anxiety was provided by both the patient and his wife. Symptoms of Anxiety: John reports that his anxiety began gradually over the past year, with symptoms occurring almost daily. He experiences excessive worry, difficulty concentrating, and occasional panic attacks. Current Symptoms: John describes feeling restless, having a racing heart, and experiencing muscle tension. He states, "I can't seem to relax, and my mind is always racing." Suicidality: John denies any suicidal ideation or intent. Anxiety Symptoms: John reports excessive worry, panic attacks, and difficulty concentrating. Substance Use: John denies any current or past substance use issues. ADHD Symptoms: John denies symptoms associated with attention deficit disorders. History of Trauma/Abuse: John denies any history of sexual, physical, or emotional abuse. Past Psychiatric History: John has no known past psychiatric history. Social/Developmental History: John grew up in a supportive family environment and identifies as Christian. He has two children, ages 10 and 12, who are dependent. Activities of Daily Living: John maintains a regular work schedule as an accountant but struggles with work-life balance. Leisure Activities: John enjoys reading and playing tennis but has reduced participation due to anxiety. Barriers to Treatment: John cites financial constraints and stigma as barriers to seeking treatment. Client’s Goals: "I want to manage my anxiety better and feel more in control of my life." Coping Strengths: Family Support: John has a supportive wife and extended family who provide emotional support. Financial Stability: John is financially stable but concerned about future expenses. Housing Status: John lives in a safe, comfortable home. Strengths/Assets: John is motivated, resilient, and in good physical health. Family History: John's father has a history of depression, and his mother has hypertension. Medical History: John has a history of hypertension, managed with medication. Exam: John appeared well-groomed, with coherent speech and a cooperative demeanor. His mood was anxious, and his affect was congruent with his mood. Mood/Affect: John exhibits signs of anxiety but no depression. Speech: Speech is normal in rate and tone. Thought Content: Logical thought processes with no delusions or obsessions. Suicidal Ideation: John denies suicidal thoughts. Insight & Judgment: John demonstrates good insight and judgment. Signs of Anxiety: Observable restlessness and occasional trembling. Attention Span & Eye Contact: John maintains good eye contact and shows no signs of distractibility. Instructions / Recommendations / Plan: John is recommended for outpatient treatment with a focus on cognitive behavioral therapy. Follow-up is advised in two weeks, with instructions to contact the clinic if symptoms worsen. Recommended Treatment Setting: Outpatient treatment. Therapeutic Approach: Cognitive behavioral therapy. Follow-up Plan: Return for a follow-up appointment in two weeks. Notes & Risk Factors: John is experiencing stress due to work demands and financial concerns. Billing Code: 90791 Bio-Psychosocial Initial Assessment Time spent face to face with patient and/or family and coordination of care: 10:30 AM - 11:30 AM Clinician Name & Credentials: Nurse Jane Smith, RN Electronically Signed By: Nurse Jane Smith, RN On: 11/01/2024 11:45 AM