Preparation

Review the Santos Family Case Study interactive media activity.

If you have not already done so, review the Week 9: DocumentationLinks to an external site. reading from the Joint Commission, Documentation of Care, Treatment, or Services in Behavioral Health Care: Your Go-To Guide.

In addition, review Biopsychosocialspiritual Assessment [PDF] for a summary of the information that should be included in a biopsychosocialspiritual assessment.

Overview

Based on the guidance provided by the Joint Commission Resources and the Biopsychosocialspiritual Assessment reading, prepare a typed, highly factual, and detailed biopsychosocialspiritual assessment report about a member of the Santos family you worked with in one of your role plays.

Pay special attention and include the information listed in the outline in the Biopsychosocialspiritual Assessment document in your report to ensure you align with current practice and documentation expectations in the field of graduate social work. This will also ensure that assessment documentation is comprehensive and that you protect your credibility and licensure, once licensed.

Once you have completed the assessment, you can more easily update and document ongoing sessions. Each agency may have a different template they request you to use. This is acceptable, but as a licensed graduate social worker, regardless of your agency’s template format, you must ensure you include the proper information. Before you assess and document, it is essential to know what your level of licensure allows in assessment and practice.

The assessment documentation in this assignment will prepare you for the highest level of clinical licensure and allow you to talk to others about what else you may need or want to add. Keep this assignment for your use and to further expand on in future social work courses and practicum education. Talk with your faculty and practice education supervisors about creating a template you can easily use in ongoing work to help prepare you for graduation and the workforce. 

Purpose

The purpose of this assignment is for you to demonstrate your ability to organize and document in a report a critical assessment on the functioning of a client and an analysis of problem areas. It should contain a clear, concise, and defensible client assessment.

Instructions

Create an Assessment Report

Prepare a detailed biopsychosocialspiritual assessment report for a member of the Santos family you worked with in one of your roleplays. In your report, include all information outlined in Biopsychosocialspiritual Assessment [PDF].

At the end of the documentation, sign the report as you, the learner social worker (including your credentials), and date it.

Report format: The report should be single-spaced with a blank space between paragraphs and/or sections. Headings should be used and bolded to make the sections in the report easy to read and easy to find. Done well, the report is probably one of the more complex documents to write. What is important is that the assessment provides sufficient information so that any other professional can read the report and clearly understand the significant aspects, problems, and strengths of the client. 

Summarize a Related Scholarly Article

In addition to your assessment report, search the Capella library databases for one scholarly (peer-reviewed) journal article related to the client’s problem or the type of intervention one would consider using with the client. It is essential that your documentation is in line with the literature and has a clear rationale as to why you are doing what you are doing. 

Using the critical thought process, write one paragraph about the article and why it was chosen. Attach the article to the report. 

Using scholarly articles in our practice with clients is one way to link research to practice. 

Additional Requirements

The assignment you submit is expected to meet the following requirements:

• Written communication: Written communication is free from errors that detract from the overall message.
• APA formatting: Resources and citations are formatted according to the current APA Style and Format. Use Academic WriterLinks to an external site. for guidance in citing sources and formatting your paper in proper APA style. See the Writing CenterLinks to an external site. for more APA resources specific to your degree level.
• Cited resources: Minimum of one scholarly source. All literature cited should be peer-reviewed and published within the past five years.
• Font and font size: Times New Roman, 12 point.

Competencies Measured

By successfully completing this assignment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

• Competency 5: Demonstrate respect for client self-determination during the assessment process by collaborating with clients and constituencies in developing a mutually agreed-upon plan. (C7.GP.B)
  • Create an assessment report for an identified client. (C7.GP.A)
  • Write a report that contains a critical assessment on the functioning of a client. (C7.GP.A)
• Competency 6: Apply theories of human behavior and person-in-environment, as well as other culturally responsive and interprofessional conceptual frameworks, when assessing clients and constituencies. (C7.GP.A)
  • Analyze identified client problem areas. (C8.GP.A)
  • Apply the critical thought process to make the connection between practice and research, integrating academic research into the assessment report, to support the assessment of the client. (C8.GP.A)
  • Collect, organize, and interpret client data. (C7.GP.A)
• Competency 8: Communicate in a manner that is scholarly, professional, and consistent with expectations for members of the social work profession.
  • Apply the standard writing conventions for the discipline, including structure, voice, person, and tone.

  View RubricBio-Psycho-Social-Spiritual AssessmentBio-Psycho-Social-Spiritual AssessmentCriteriaRatingsPtsCreate an assessment report for an identified client. (C7.GP.A)view longer description34 to >28.9 ptsDISTINGUISHEDCreates an assessment report for an identified client, and makes a strong connection to real-world situations.28.9 to >23.8 ptsPROFICIENTCreates an assessment report for an identified client.23.8 to >0 ptsBASICCreates an inconsistent assessment report for an identified client.0 ptsNON_PERFORMANCEDoes not create an assessment report for an identified client./ 34 ptsWrite a report that contains a critical assessment on the functioning of a client. (C7.GP.A)view longer description25.5 to >21.68 ptsDISTINGUISHEDWrites a report that contains an exceptionally rigorous critical assessment on the functioning of a client.21.68 to >17.85 ptsPROFICIENTWrites a report that contains a critical assessment on the functioning of a client.17.85 to >0 ptsBASICWrites a report that contains an assessment on the functioning of a client.0 ptsNON_PERFORMANCEWrites a report that inadequately assesses the functioning of a client./ 25.5 ptsAnalyze identified client problem areas. (C8.GP.A)view longer description25.5 to >21.68 ptsDISTINGUISHEDAnalyzes identified client problem areas with exceptional rigor.21.68 to >17.85 ptsPROFICIENTAnalyzes identified client problem areas.17.85 to >0 ptsBASICDescribes identified client problem areas.0 ptsNON_PERFORMANCEDoes not describe identified client problem areas./ 25.5 ptsApply the critical thought process to make the connection between practice and research, integrating academic research into the assessment report, to support the assessment of the client. (C8.GP.A)view longer description25.5 to >21.68 ptsDISTINGUISHEDApplies the critical thought process with exceptional rigor to make the connection between practice and research, integrating academic research into the assessment report, to support the assessment of the client.21.68 to >17.85 ptsPROFICIENTApplies the critical thought process to make the connection between practice and research, integrating academic research into the assessment report, to support the assessment of the client.17.85 to >0 ptsBASICDescribes the critical thought process for making the connection between practice and research, integrating academic research into the assessment report, to support the assessment of the client.0 ptsNON_PERFORMANCEDoes not describe the critical thought process for making the connection between practice and research, integrating academic research into the assessment report, to support the assessment of the client./ 25.5 ptsCollect, organize, and interpret client data. (C7.GP.A)view longer description25.5 to >21.68 ptsDISTINGUISHEDCollects, analyzes, organizes, and interprets client data.21.68 to >17.85 ptsPROFICIENTCollects, organizes, and interprets client data.17.85 to >0 ptsBASICCollects client data, but does not organize or interpret it in a meaningful way.0 ptsNON_PERFORMANCEDoes not collect client data./ 25.5 ptsApply the standard writing conventions for the discipline, including structure, voice, person, and tone.view longer description34 to >28.9 ptsDISTINGUISHEDExhibits strict adherence to the standard writing conventions for the discipline. Elements of structure, voice, person, and tone are well matched to the intended audience.28.9 to >23.8 ptsPROFICIENTApplies the standard writing conventions for the discipline, including structure, voice, person, and tone.23.8 to >0 ptsBASICApplies writing conventions that are inconsistent with disciplinary standards or inappropriate for the intended audience.0 ptsNON_PERFORMANCEDoes not apply the standard writing conventions for the discipline./ 34 pts