BLOOD AND MARROW TRANSPLANT

PSYCHOSOCIAL ASSESSMENT

OUTLINE VERSION

Patient’s Name ______Date of Assessment ______

Identifying Information

  • Demographic Information - Name, age, sex, marital status
  • Family Composition
  • Current living arrangements (temporary, permanent)
  • Telephone contact numbers, e-mail access
  • Formal education

Employment and Financial Information

  • Employment status, occupation
  • Sources of income
  • Identifyprimary wage earner
  • Insurance coverage for transplant and out-of-pocket expenses (lodging, meals, transportation)
  • Ability to maintain insurance
  • Disability insurance, income maintenance
  • Prescription coverage
  • Other financial concerns

Present Illness/Medical Information

  • Diagnosis and date of diagnosis
  • History of disease process
  • Treatments and side effects
  • Adjustment to illness/ treatment
  • Functional Ability (activities of daily living)
  • Treatment plan /transplant protocol

Cognitive Functioning

  • Mental Status
  • Literacy & learning disability concerns that may impact compliance with medications or medical follow-up and understanding of treatment, informed consent
  • Level of concentration
  • Learning ability (preferred learning methods)
  • Preferred method of communication

Psychosocial History

  • Current emotional status
  • Mental health history
  • Family mental health history
  • Medication history – specifically psychotherapeutic medications
  • Past/present involvement with counseling and/or support groups
  • Alcohol/Drug use/abuse history
  • Significant events in past five years—marriage, divorce, death, job loss or change, move
  • Relationship history
  • Hobbies/interests

Coping Skills

  • Strengths and Weaknesses
  • Receptiveness to psychosocial interventions
  • Past/present coping techniques or problem-solving skills
  • Use ofComplementary & Alternative Medicine
  • History of significant losses
  • Family history of cancer or chronic illness

Family Assessment and Support Systems

  • Marital Relationship
  • Parent/child relationship(s)
  • Relationship with extended family
  • Familial adaptation to illness
  • Familial coping patterns/problem-solving skills
  • Identify patient’s support system(s)
  • Identify caregiver(s) support systems
  • Caregiver during BMT
  • Anticipated family involvement
  • Spirituality/faith traditions
  • Cultural traditions
  • Friends and other sources of support
  • Community support

Issues Related to BMT

  • Level of understanding of BMT (length of recovery, risk)
  • Concerns about BMT
  • Caregiver for BMT
  • Living arrangements during BMT
  • Post Transplant plans
  • Advance directives
  • Legal issues such as financial power of attorney

Clinical Assessment and Impressions

  • Strengths of patient/family
  • Patient/family adjustment to illness
  • Lifestyle & role changes/stressors
  • Developmental stage issues/concerns

Plan of Care/Interventions

Updated on 3/26/09Page 1 of 2