Clinical template
Biopsychosocial Assessment Template with Examples
A biopsychosocial assessment puts biology, psychology, and social context on the same page. George Engel argued for that in 1977. In Canadian primary care and community mental health it is how you stop treating a PHQ-9 as if it were a housing history.
Blank biopsychosocial template
Use this for a new mental-health intake, a complex primary-care visit, or a community-team admission. Carry the same problem into formulation and plan so the social work referral is not an afterthought under 'P: follow up PRN.'
Biopsychosocial assessment
Date / clinician / setting / informants: Patient: [initials, age, pronouns] | Reason for assessment: BIOLOGICAL Medical / psychiatric diagnoses, onset: Medications / substances / withdrawals: Sleep, appetite, energy, pain, cognition: Family psychiatric / medical history: Investigations relevant today: PSYCHOLOGICAL Current symptoms (mood, anxiety, psychosis, trauma, OCD as relevant): Risk: SI/HI/self-harm, means, protective factors: Personality / coping / attachment themes (if known, not guessed): Past treatment and what helped: Strengths / values: SOCIAL Housing / food / income / employment / school: Relationships / caregiving / isolation: Education / language / immigration / legal: Culture, community, discrimination, colonial or racialized stressors (in the patient's words): Access: OHIP/MSP/RAMQ or uninsured, transportation, childcare, wait-lists: FORMULATION (one paragraph: why this person, why now) BIO: PSYCHO: SOCIAL: PLAN (match each column) Biological interventions: Psychological interventions: Social interventions / navigation: Safety / follow-up / who owns what:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, or for the patient's own account of culture and community. Review every generated note before it enters the chart.
Engel's three columns, in clinic
Engel was arguing against a medicine that treated disease as only pathophysiology. He was not arguing against diagnosis. You still name major depression, heart failure, or alcohol withdrawal when that is the working diagnosis. You also name the overtime, the eviction notice, and the fact that the only counsellor is a six-month wait.
| Column | Questions that belong | Failure mode |
|---|---|---|
| Biological | Illness, meds, substances, sleep, pain, labs, family history | A DSM label with no exam, no meds, no withdrawal risk |
| Psychological | Symptoms, meaning, coping, trauma history if offered, risk | Personality labels after one visit |
| Social | Housing, money, work, legal, racism, access to care | 'Lives with family' as the entire social history |
Public Health Agency of Canada and every province's public-health notes list income, education, employment, social support, housing, and early childhood as determinants. You do not need to paste that list. You do need to ask whether this person can fill the prescription you just wrote.
Example 1 — primary care, depression and money
Family medicine intake
41-year-old man, Hamilton. 30-minute visit. Fictional.
Reason: "I can't get out of bed and I'm going to lose the apartment." BIO No prior psychiatric diagnosis. PHQ-9 = 18. Sleep 3–4 h, appetite down, weight −4 kg / 6 weeks. Drinks 8–10 beer most nights, no morning tremor, last drink last night. No current SI plan; passive death wishes. TSH, CBC last year normal. Father had "nervous breakdown," no details. Knee pain on diclofenac PRN. PSYCHO Anhedonia, guilt about providing, concentration poor. No mania. No psychotic symptoms. Coping: isolation, alcohol. Strengths: still showing up to work some days, close with sister in Stoney Creek. SOCIAL Construction labour, cash and T4 mix, hours cut. Rent $1,650, behind one month. Food from sister. Separated, sees kids weekends. OHIP covered. No extended benefits. Unhoused risk in 4–6 weeks if arrears continue. FORMULATION 41M with a first moderate depressive episode in the setting of alcohol, sleep loss, and imminent housing loss. Biology: mood + alcohol. Psychology: guilt, shrinking coping. Social: income shock and arrears driving the crisis as much as the PHQ-9. PLAN Bio: start sertraline 50 mg daily; counsel activation and 2-week review; thiamine; CBC, TSH, ferritin, B12, GGT now; alcohol reduction plan, not forced abstinence today. Psycho: crisis line numbers, safety plan, counselling referral (sliding scale). Social: same-day social-work navigation for rent bank / Ontario Works if eligible; letter for housing worker stating functional impairment dates; sister as practical support if he consents. RTC 10 days. ED if SI with plan.
Example 2 — community mental health
Early-psychosis intake
19-year-old woman, Regina. Team assessment. Fictional.
Informants: patient and mother. Reason: 3 months of withdrawing, failed semester, mother hears her talking in the bedroom. BIO No meds. Cannabis daily since 17, more recently. Sleep reversed. Appetite OK. No head injury. Maternal uncle with schizophrenia. Urine tox pending. Pregnancy test negative today. PSYCHO Guarded. Describes "comments" from classmates that may be ideas of reference. No command hallucinations volunteered. Insight partial. Risk: no SI/HI today; mother hiding kitchen knives on her own initiative — explore, do not ignore. Strengths: wants to go back to classes, previously high functioning. SOCIAL Lives with parents. International student, Saskatchewan health coverage in place. Tuition stress. Few friends on campus after the last semester. No current job. Experiences racist comments on transit — she names this; do not collapse it into "paranoia" without checking. FORMULATION 19F with a first episode of possible psychosis, cannabis use, family history, academic collapse, and social isolation. Differential includes substance-induced and primary psychotic disorder. Social stressors are real and concurrent, not an explanation that removes the need for a mental-status exam and follow-up. (MSE lives on the dedicated page / in the exam section of the chart, not as a substitute for this formulation.) PLAN Bio: offer antipsychotic discussion with psychiatrist this week; reduce cannabis; medical workup per EPI protocol. Psycho: low-stimulus psychoeducation with mother; no knives narrative without a documented risk assessment. Social: campus accessibility, student-aid office, racism/support resources she chooses; do not notify school without consent except where duty to report applies. Urgent psychiatry slot; after-hours crisis plan given.
Example 3 — older adult, rural primary care
Heart failure and isolation
76-year-old woman, rural PEI. Home visit with NP. Fictional.
Reason: recurrent admissions for HFpEF, missed pills, "I don't see anyone." BIO HFpEF, AF on apixaban, CKD 3, T2DM. Weights up 3 kg / 10 days. Blister pack started last admission, half unused. Hearing aids not worn. MoCA 22/30 last month — cognitive screen, not a diagnosis today. Pain: knees. PSYCHO Low mood, not meeting MDD threshold last PHQ. Fear of another hospital stay. Pride in staying in the house her husband built. No SI. SOCIAL Widowed 2 years. Nearest daughter in Halifax. Homecare 1x/week. Drives only in daylight, winter coming. Food is tea and toast some days. Heat is oil, worried about the tank. Veterans' benefits through late husband — paperwork stalled. FORMULATION 76F with decompensated HFpEF whose missed diuretics sit on top of isolation, food, fuel, and a stalled benefit file. Treating the ejection fraction without the kitchen will bounce her back to Queen Elizabeth Hospital. PLAN Bio: restart blister with homecare observed doses if she agrees; same-week MRP/NP heart-failure review; hearing-aid batteries. Psycho: name the fear of hospital; no new antidepressant today. Social: increase homecare; Meals on Wheels; veterans' paperwork with the legion service officer she already knows; daughter call with consent; winter driving plan. Follow-up home visit 1 week. Weight log on the fridge.
Mistakes in biopsychosocial notes
- A biological plan only (start sertraline) with a social crisis unaddressed.
- Social history as marital status and 'non-smoker.'
- Cultural or racialized stress interpreted as psychopathology because nobody asked.
- Formulation that restates the HPI in three headings with no 'why now.'
- Personality diagnosis after a single primary-care visit.
- Ignoring that the patient cannot pay for the psychotherapy you recommended.
Draft the three columns from the visit
Scribeberry listens to the encounter, or takes dictation, and drafts a biopsychosocial assessment in your headings. Edit formulation and risk, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a biopsychosocial assessment?
It is a clinical formulation that accounts for biological illness, psychological symptoms and meaning, and social determinants — housing, income, relationships, access — in one assessment. George Engel described the model in 1977.
Who uses biopsychosocial assessments in Canada?
Family physicians, NPs, psychiatrists, social workers, occupational therapists, and community mental-health teams. Primary care uses a shorter version every time a prescription will fail because of rent or language.
Is this the same as a mental status exam?
No. The MSE is a structured description of appearance, thought, and cognition at one point in time. A biopsychosocial assessment is the formulation of why this person is unwell now, including life context. Keep them as separate sections.
Can Scribeberry generate a biopsychosocial assessment?
Yes. Use a BPS template, record or dictate, and generate the three columns plus a plan. You review risk, social facts, and anything the patient said about culture or identity before signing.
Templates
