Free Nursing Home Psychosocial Assessment Template
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 |
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Name: |
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Date of Birth: |
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Gender: |
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Date of Admission: |
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Room Number: |
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Medical Record Number: |
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Date of Assessment: |
Assessment Information |
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Assessment Completed By: |
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Relationship to Resident: |
Section I: Identifying Information |
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Primary Language: |
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Marital Status: |
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Living Arrangements Before Admission: |
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Religion/Spiritual Preference: |
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Ethnicity/Race: |
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Occupation: |
Section II: Medical History |
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Primary Diagnosis: |
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Other Medical Diagnoses/Conditions: |
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Allergies: |
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Current Medications: |
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Physician Information: |
Section III: Social History |
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Family/Support System: |
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Living Situation Prior to Admission: |
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Educational Background: |
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Military Service: |
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Hobbies/Interests: |
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Financial Resources: |
Section IV: Psychosocial Assessment |
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Mental Health History: |
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Cognitive Status: |
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Emotional Status: |
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Behavioral Observations: |
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Socialization Skills: |
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Support System: |
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Stressors/Concerns: |
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Coping Mechanisms: |
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Goals/Desires: |
Section V: Environmental Assessment |
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Physical Environment: |
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Safety Concerns: |
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Accessibility: |
Section VI: Recommendations/Plan of Care |
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Social Services Interventions: |
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Interdisciplinary Team Involvement: |
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Referrals: |
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Goals: |
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Plan of Action: |
Section VII: Signatures
[Month, Day, Year]
[Month, Day, Year]
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