Nursing Home Psychosocial Assessment

This Nursing Home Psychosocial Assessment serves as a comprehensive tool to evaluate the psychosocial needs of residents. Complete each section thoroughly to provide holistic care and support. Ensure compliance with US law/standards throughout the assessment process.

Resident Information
Name:
Date of Birth:
Gender:
Date of Admission:
Room Number:
Medical Record Number:
Date of Assessment:

Assessment Information
Assessment Completed By:
Relationship to Resident:

Section I: Identifying Information
Primary Language:
Marital Status:
Living Arrangements Before Admission:
Religion/Spiritual Preference:
Ethnicity/Race:
Occupation:

Section II: Medical History
Primary Diagnosis:
Other Medical Diagnoses/Conditions:
Allergies:
Current Medications:
Physician Information:

Section III: Social History
Family/Support System:
Living Situation Prior to Admission:
Educational Background:
Military Service:
Hobbies/Interests:
Financial Resources:

Section IV: Psychosocial Assessment
Mental Health History:
Cognitive Status:
Emotional Status:
Behavioral Observations:
Socialization Skills:
Support System:
Stressors/Concerns:
Coping Mechanisms:
Goals/Desires:

Section V: Environmental Assessment
Physical Environment:
Safety Concerns:
Accessibility:

Section VI: Recommendations/Plan of Care
Social Services Interventions:
Interdisciplinary Team Involvement:
Referrals:
Goals:
Plan of Action:

Section VII: Signatures

[Month, Day, Year]

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