General Practitioner Template

BPS

A professional General Practitioner template for healthcare professionals.

About this template

The Biopsychosocial Assessment template is a comprehensive tool used by General Practitioners to evaluate a patient's biological, psychological, and social factors affecting their health. This template helps clinicians gather detailed information on physical health, mental well-being, and social circumstances, enabling a holistic approach to patient care. It is particularly useful for creating a thorough understanding of a patient's condition and planning effective treatment strategies. When used with Heidi, this template ensures a structured and efficient documentation process, enhancing the quality of patient records and facilitating better healthcare outcomes.

Preview template

Biopsychosocial Assessment: Biological: - The patient presents with hypertension and type 2 diabetes, managed with medication. They report occasional headaches and fatigue. - Past medical history includes appendectomy in 2015 and treatment for a fractured wrist in 2020. - Current medications include Metformin, Lisinopril, and a daily multivitamin. - The patient has a known allergy to penicillin. Psychological: - The patient reports experiencing anxiety and mild depression, with symptoms including restlessness and difficulty concentrating. - Past psychiatric history includes therapy for anxiety in 2018, with no hospitalizations. - Cognitive functioning appears intact, mood is anxious, and affect is congruent with mood. - No psychological assessments or tests have been conducted recently. Social: - The patient lives with their spouse and two children, with a supportive family dynamic. - They are employed as a teacher and report job satisfaction but occasional stress due to workload. - The patient resides in a stable housing situation and is actively involved in community activities. - No legal issues or involvement with the criminal justice system reported. - The patient occasionally consumes alcohol socially and denies any drug or tobacco use. Summary and Plan: - Key findings include well-managed diabetes and hypertension, anxiety symptoms, and a supportive social environment. - The treatment plan includes a referral to a mental health specialist for anxiety management, continuation of current medications, and a follow-up appointment in three months. - Patient education provided on lifestyle modifications to manage stress and improve overall health.

Biopsychosocial Assessment: Biological: - [describe current physical health issues, medical conditions, and symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention past medical history, previous surgeries, and treatments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [list current medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Psychological: - [describe current mental health issues, symptoms, and concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention past psychiatric history, previous treatments, and hospitalizations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe cognitive functioning, mood, and affect] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention any psychological assessments or tests conducted] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Social: - [describe social history, including family dynamics, relationships, and support systems] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention occupational history, current employment status, and work-related issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe living situation, housing stability, and community involvement] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention any legal issues or involvement with the criminal justice system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe substance use history, including alcohol, drugs, and tobacco] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Summary and Plan: - [summarize key findings from the biological, psychological, and social sections] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [outline the proposed treatment plan, including referrals, follow-up appointments, and interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention any patient education or counseling provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)

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