Biopsychosocial Assessment Template with Examples

What is a Biopsychosocial Assessment Template?

A biopsychosocial assessment template is a tool that guides clinicians in the completion of a holistic, person-centred assessment using the biopsychosocial model used in Australia. By using comprehensive prompts and a predefined structure, templates can improve the efficiency, accuracy, and consistency of biopsychosocial assessments.

The biopsychosocial model recognises that health and illness reflect the interaction between a patient's biological, psychological, and social circumstances. Moving the assessment beyond just symptoms, it’s the clinical framework underpinning mental health treatment plans (MHTPs), chronic disease management (CDM) plans, and complex case reviews in Australian general practice and hospital settings.

In this article, we’ll explore the theoretical foundations of the biopsychosocial model and then discuss how biopsychosocial assessment templates are used in clinical settings. We’ll also explain how AI-enabled templates can reduce the cognitive load involved in completing these complex assessments, giving clinicians more mental space to engage patients.

The Biopsychosocial Model Explained

The biopsychosocial model was first proposed in 1977 by George Engel as an alternative to the then-dominant biomedical model of medicine. While Engel acknowledged the great advances of biomedicine, he argued that a purely physiological approach to healthcare was insufficient for many aspects of medical treatment and research.

When it comes to the Australian healthcare context, his framework now underpins some of the widely used care pathways in clinical practice, including RACGP-trained GP consultations to MHTPs.

The defining feature of the biopsychosocial model is that illness does not arise solely from biochemical alteration but from the interaction of diverse causal factors at molecular (biological), individual (psychological), and societal (social) levels.

Engel stressed the importance of the subjective experience of patients with their illness. Plus, he also claimed that the patient-clinician relationship is a vital ingredient in the success or failure of medical treatment.

Present-Day Relevance

The biopsychosocial model was controversial at the time it was conceived. But today, most of its core propositions are widely accepted as simply being part of delivering high-quality, holistic, patient-centered care.

For example:

• Social determinants of health are recognised as strongly correlated with health outcomes across individuals and communities. The AIHW's Australia's Health report and the ACSQHC's work on health equity provide the evidence base that clinicians and health systems draw on.
• Mental health screening and treatment (where required) are seen as a vital part of chronic disease management.
• Consumer involvement in the development of healthcare policy, research, and clinical practice guidelines is now commonplace (if not mandated by health authorities).

For clinicians in Australia, the question is not so much whether the biopsychosocial model is relevant, but to what extent psychological and social needs are incorporated into the healthcare delivery process.

Biopsychosocial Assessment Templates in Clinical Settings

Across specialties, biopsychosocial assessment templates encourage a balanced view of each patient’s medical and personal situation. This holistic framework, when utilised, ensures that vital information that could impact a patient’s treatment and recovery is not missed.

Here are some examples of the often-overlooked, yet important information biopsychosocial assessment templates might uncover in different clinical settings:

• Surgical Care - Social factors such as an unstable home environment or substance misuse, which could impact adherence to post-discharge follow-up care.
• Psychiatry - Medical or social issues that are not adequately managed or may even be contributing to psychopathology (eg., unmanaged diabetes or loneliness).
• General Practice - Psychological challenges such as depression that might impair a patient’s ability to self-manage their chronic disease.
• Geriatric Medicine - Indicators and risk factors for elder abuse, including signs clinicians can raise with the National Elder Abuse phone line (1800 ELDERHelp). Non-obvious causes of memory impairment, such as inadequate nutrition.
• Emergency Medicine - The true etiology of a patient’s present complaint. This can be an accidental injury that may actually be due to domestic violence or self-harm.

After evaluating with a biopsychosocial assessment template, the clinician (or MDT) will be aware of the full spectrum of a patient’s needs. This comprehensive approach supports the development of a treatment or care plan (whether a GP Management Plan, CDM plan, or specialist treatment plan) that addresses both immediate and ongoing care needs.

Who Completes the Biopsychosocial Assessment Template?

In most cases, a formal biopsychosocial assessment is completed by an accredited mental health social worker, psychologist, or other mental health clinician. Unlike most regulated health professions in Australia, social work is not yet nationally registered under AHPRA - accreditation instead runs through the Australian Association of Social Workers (AASW)

In reality, however, virtually all clinicians regularly complete assessments incorporating biopsychosocial elements.

Look through any template for completing a patient intake form, medical history, or discharge summary, and you'll notice prompts to include information about a patient’s medical, psychological, and social situation.

These documents are generally not considered a full biopsychosocial assessment, yet they share the same aim of promoting comprehensive, patient-centred care.

Using AI to Speed Up and Improve the Process

A good biopsychosocial assessment template can make the process of completing holistic patient evaluations more efficient, yet clinicians still usually work under significant time pressure.

Furthermore, the sheer volume of information that must be collected can make clinicians feel like they have to focus more on the assessment than on the patient, which can negatively impact the quality of care.

Shanan at SANA Physiotherapy in Sunshine Coast, Australia, now saves 4 to 5 hours a week on documentation, even across just three clinical days.

He puts it plainly: "The level of detail I'm getting from Heidi would have taken me an additional 6-7 hours to do manually."

Patient notes and GP letters that once took hours, sometimes days, now take minutes. Time was dedicated to the patients and the business, not paperwork.

How to Write a Biopsychosocial Assessment with Examples

There are two broad types of biopsychosocial assessment templates:

1. Those using dedicated biological, psychological, and social headings (like the example below).
2. Templates that cover domains of the assessment through a large number of headings (like the sample PDF in this article).

In both types of biopsychosocial assessment templates, headings and prompts guide the clinician through a comprehensive assessment of the patient’s situation. Information may be gathered from a variety of sources, including medical records, patient interview, clinical notes, and discussions with family, caregivers, and other involved professionals and support people.

To give you an idea of what the completed document produced by a biopsychosocial assessment template might look like, here’s a shortened example following the 3-heading style.

Example Biopsychosocial Assessment

This biopsychosocial assessment was completed by a resident medical intern at a community geriatric clinic in response to a referral from the patient’s primary care doctor.

Biological

This section covers all aspects of the patient’s physical health and medical history. Biopsychosocial assessment templates often include prompts to explore the patient’s:

• Current medical conditions and management
• Previous medical history
• Family medical history
• Past significant accidents or injuries
• Biological functions (sleep, nutrition, energy, pain, etc)
• Functional ability (activities of daily living)

Example note

Patient presents with Type 2 diabetes (diagnosed 2019), hypertension, and chronic lower back pain following work injury in 2021. Currently prescribed metformin 1000mg BD, lisinopril 20mg daily, and as-needed ibuprofen for pain. Reports disturbed sleep (averaging 5 hours per night) due to pain and frequent urination.

Family history significant for cardiovascular disease and diabetes on paternal side. BMI currently 32.4, indicating obesity. Client reports sporadic meal patterns and frequent consumption of processed foods. Referral from GP expresses concern over poorly managed diabetes, with last HbA1c being 63 mmol/mol (7.9%).

Psychological

Describes the patient’s mental health status, cognitive functioning, and emotional well-being. A mental state examination may be conducted if warranted.

Common prompts under the psychological heading in a biopsychosocial assessment template include:

• Mental health history, diagnoses, and treatments
• Current emotional state and mood patterns (observed and self-described)
• Cognitive functioning, including results of any formal testing
• History of trauma or significant life stressors
• Substance use patterns and history
• Notable psychological strengths or vulnerabilities
• Mental health risk assessment (if indicated)

Example note

Patient describes symptoms consistent with moderate depression, including persistent low mood, anhedonia, fatigue, and difficulty concentrating. Symptoms have been present for the past 8/12, worsening following redundancy 3/12 ago. Reports nil current suicidal ideation but acknowledges passive thoughts of "not wanting to be here anymore" (denies suicidal plan or intent).

PMHx of anxiety disorder diagnosed in early 20s with previous positive response to CBT. Client acknowledges using ETOH "to relax" (approx 3-4 standard drinks NOCTE). No prior psychiatric hospitalisations. Patient identifies primary coping strategies as distraction through television and "keeping busy," but acknowledges these are becoming less effective.

Social

Explores the patient’s relationships, support systems, socioeconomic functioning, and any areas of social stress. Standard prompts in a biopsychosocial assessment template cover:

• Current relationship and family situation
• Social support network
• Housing and financial situation
• Employment status and work history
• Educational background
• Cultural identity and spiritual beliefs
• Community engagement and recreational activities

Example note:

Patient lives alone in a one-bedroom unit following divorce 2 years ago. Reports a strained relationship with ex-spouse but maintains close relationships with two adult children (ages 22 and 26) who live in neighbouring suburbs and visit monthly. Recently made redundant after 15 years in manufacturing due to company downsizing. This has resulted in financial strain and concerns about maintaining housing.

Completed Year 12 education with some TAFE training. Identifies as a non-practicing Catholic. Patient’s primary social support comes from weekly phone calls with sister. Reports social isolation since job loss with no hobbies, friends, or regular activities outside the home. Patient expresses interest in local community centre programs (e.g., Men's Shed) but is unsure of how to start the process of attending.

Assessment and Plan

The final part of a biopsychosocial assessment template is the plan. This section synthesizes all available information to create a summary of the patient’s situation and recommendations for next steps.

Topics to address in the assessment and plan section include:

• Summary of key findings and diagnostic impressions
• Problems, risks, and protective factors
• Patient’s goals and views about their situation
• Treatment recommendations and referrals
• Follow-up plans and timeline

Example note

Mr. Jones is a 66-year-old man referred via his GP due to poor diabetes control in the context of likely depression and multiple social stressors. Current medications include metformin 1000mg BD, perindopril 20mg DAILY, and ibuprofen PRN for pain.

Patient describes experiencing mild-moderate depressive symptoms for the past 8/12, worsening following an unexpected job loss 3/12. Expresses passive thoughts of “not wanting to be here anymore,” with nil active suicidal plan or intent. Mr. Jones has minimal social support, living alone following divorce 2 years ago. He maintains contact with his sister and adult sons, but in-person contact is rare. Nil hobbies or activities outside of the home. Under financial strain, but suitability or desire for employment is unclear.

Discussed further assessment by members of the MDT with Mr Jones, including a Psychiatry R/V next week. He agreed and is happy to attend the clinic when instructed. Psychoeducation provided regarding depression. Patient has a reasonable level of insight and willingness to engage in treatment. Given emergency mental health numbers (e.g., Lifeline, local mental health triage) and provided assurance he will utilise these if mental state deteriorates.

Plan:

• Refer to psychiatry for assessment and opinion. Confirmed that an appointment can be offered within 1/52.
• Refer to social work to explore options for financial (e.g., Centrelink entitlements) and social support.
• Follow-up in clinic in 2/52, with appointments to see geriatrician and dietitian

As you can see from the example above, there’s a lot of information to cover in a biopsychosocial assessment. Not only does the assessment take a long time.

But because most biopsychosocial assessment templates can run 3, 4, 5 or even more pages long, it’s common for clinicians to feel like they’re paying more attention to filling out the form than to engaging with the patient.

Free Biopsychosocial Assessment Templates