First, the principle of medical record writing
1. Third person writing is required.
2. The content should be concise and to the point.
3. Be guided by facts and symptoms.
4. Avoid writing important information about others.
5. Indicate the source of information appropriately.
6. Length: 5.6 lines of A4 paper is enough. (The more detailed the record, the greater the possibility and risk of privacy exposure. )
Second, the reference format
Different genres, the focus of the record is also different.
1. Focus consultation (case information, chief complaint, goal, resources, one small step, consultation ideas)
2. Benchmark format
(1) Example of general case record
Tenth consultation.
Tell cases on time, complain about interpersonal troubles, assist cases to explore the possible causes of people's troubles, provide role-playing exercises, and encourage individuals to realize their possible shortcomings. Individual cases and the feelings of important people are also the focus of this interview. Encourage cases to develop the habit of paying attention to their words and deeds at any time. Suggest continuing to discuss the case.
Signature of consultant:
(2) Example of 2)SOAP case record
The fifth psychological consultation in May 2008 /2 1
Student: Subjective.
Customers live a very tired life. When he went home for his holiday, he had to put up with his parents' quarrels all day. When he returned to Taipei, he felt uneasy and guilty. He doesn't know why he has been in a bad mood.
0: Target
The client came to the interview on time, looking anxious and tired, eager to clarify his difficulties and concerns, hoping to get better soon.
A: Assessment.
The worry and anxiety of the parties have improved slightly, but the parties have obvious strict self-requirements, which are easy to cause anxiety and guilt.
P: plan
Conduct weekly psychological counseling, provide understandable psychological counseling, help the parties to detect the possible root causes behind anxiety and guilt, and learn to relax their strict requirements.
Signature of consultant: