New York State Medical Treatment Guidelines for Personality / Psychological / Psychosocial Clinical Evaluation for Pain Management in workers compensation patients

The guidelines presented by the New York State Workers Compensation Board provide fundamental principles for conducting psychosocial evaluations. These directives are crafted to assist mental health professionals in identifying appropriate methods for assessing psychosocial factors within the context of comprehensive care.

Mental health professionals with expertise in conducting psychosocial evaluations can depend on the guidance outlined by the Workers Compensation Board to make informed decisions about the most suitable approaches for their clients.

It is important to stress that these guidelines are not intended to replace clinical judgment or professional expertise. The psychosocial evaluation process should involve collaboration between the mental health professional and the client, taking into account individual circumstances and needs.

Psychosocial Evaluation

  • Psychosocial evaluations are necessary to determine if additional psychosocial or behavioral interventions are needed for patients diagnosed with non-acute pain. These evaluations offer insights into the patient’s social environment, aiding in more effective rehabilitation.


Clinical Evaluation

  • A psychiatrist or psychologist should conduct a clinical evaluation, covering:
  • History of Injury:
    • Description of the injury in the patient’s own words or similar language, with caution when using translators.
    • Details regarding the nature and circumstances of the injury, current symptoms, extent of medical validation, treatment received, compliance, and coping strategies.

    Health History:

    • Medical history, psychiatric history, history of alcohol or substance use, activities of daily living, previous injuries, and disability.

    Psychosocial History:

    • Childhood history including abuse/neglect, educational background, family history, marital history, legal history, employment history, military service, exposure to trauma, signs of pre-injury psychological issues, interpersonal relationships, living situation, and financial history.

    Mental Status Examination:

    • Assessment of cognition, affect, mood, orientation, thinking, and perception.

    Risk Assessment:

    • Evaluation of any potential danger to self or others.

    Psychological Test Results:

    • If conducted, results of psychological tests.

    Psychiatric Diagnosis:

    • Identification of current psychiatric diagnoses according to established standards.

    Pre-existing Psychiatric Conditions:

    • Treatment considerations for pre-existing psychiatric conditions affecting recovery from non-acute pain.

    Treatment Recommendations:

    • Recommendations tailored to specific goals, frequency, timeframes, and expected outcomes.


Tests of Psychological Functioning

  • Psychometric testing is valuable for assessing mental conditions, pain conditions, and cognitive functioning. It aids in treatment planning, vocational planning, and evaluating treatment effectiveness.
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