醫務社會個案工作實務過程中常見評估至處遇間的斷裂，使實務工作者問題解決效能與專業地位受到質疑與威脅。本研究透過行動研究方法建構發展BPSS矩陣評估模式並投入應用，以期解決評估與處遇計畫間斷裂問題。自2008年中旬至2022年7月，歷時14年，歷經困境感知、粗架構建構、各面向細部內容分類與修訂，及個案紀錄格式建構與凝聚主診斷四個循環階段。本行動研究發現BPSS矩陣基礎的個案實務工作，能有效彙整身心社靈四個面向資訊，整理出病人承受的各種影響及後續因應調適等資料，做為問題處遇之基礎，並深入處理案主問題與需要。BPSS矩陣基礎實務更進一步評核處遇效果，追蹤個案後續生活變化，使各工作階段充份連結，有效解決實務上遭遇到的困境。

In medical social work practice, the discrepancy can be frequently identified in the process from assessment to intervention, which undermines the effectiveness of problem-solving and the professional status of practitioners. This study was based on action research to develop BPSS Matrix Assessment Model and applied it in medical settings to fill the medical social work practice gap. This study was conducted over fourteen years, from mid-2008 to July 2022. Four cyclical phases were divided into Adversity Perception, Rough Framework Construction, Classification and Revision of Detailed Content in Various Aspects, and Construction of Case Record Formats and Consolidation of Main Diagnoses. The study exhibits that the BPSS matrix-based casework practice enabled medical social workers to collect and organise information effectively on the physical, mental, social, and spiritual dimensions of patients so as to the various impacts caused by the illness they encountered, which led to subsequent coping and adjustment. Consequently, the information was consolidated to address problems and needs. Furthermore, the BPSS matrix-based casework practice evaluated the effectiveness of the treatment and follow-up with patients’ subsequent life changes. Ensuring an overarching connection between all phases of the casework practice and effectively resolving the practical difficulties encountered.