The medical history is a document that contains relevant information about the patient’s present and past health, including current health status, illnesses suffered to date, and family history. Very valuable information for any medical professional, especially for psychologists since they use it as a fundamental tool for diagnosis.
But what is the psychological clinical history model ? Below we tell you the elements that any medical history for psychology should include.
Below, we present an example of a psychology clinical history. A psychological history that is as complete as possible has the following elements.
Association and flow of ideas and language characteristics
Reasons why the patient has attended the psychologist’s consultation written briefly and verbatim. It includes the business phone list symptoms, date of onset, and possible events associated with its appearance.
Patient history
Psychological problems that you may have suffered in the past. Data from the pre, peri and postnatal period, psychomotor and language development, diet, sleep habits…
Social profile
Profile of the patient’s social relationships. The relationships with the people around them partner, friends and family, co-workers, etc.are recorded here, as well as how they have been throughout their childhood and adolescence.
Personality
The most relevant psychological characteristics of the patient are described, something that is revealed through the psychological interviews that are carried out during the consultation.
Includes the basis for the clinical impression or diagnosis
Family history
Relevant data about the patient’s family.
Sensorium
Memory
Thought
Test result
Diagnosis
Psychological orientation plan
Objective of the treatment and techniques to use to achieve them
Clinic Cloud, the best software for medical history management
Would you like to have your patients’ medical history always at hand to access it at any time? With our psychological medical history management software it is possible.
Clinic Cloud offers you to save all your patient records in the cloud, so you can access them from any device connected to the internet. Don’t worry, because your patients’ information will be safe on our servers, which comply with all security standards and the highest standards established by data protection laws.
In addition, you can configure as many history models as you want, to customize them according to your needs. Try Clinic Cloud for free and without BO Leads obligation, you will discover why more and more clinics are choosing our psychology software to manage their daily lives.