Counseling records, like hospital cases, are an important basis for representing the real occurrence of psychological counseling. The consultation record is like a professional bumper for psychological counselors. It can not only present the development process of consultation truthfully, but also protect itself as evidence in case of disputes with visitors, provided that the records made by consultants must be standardized, and irregular consultation records are likely to be counterproductive.
Refer to how to write consultation records in the near future. The main contents of the book, and access to relevant information, arranged the necessary desk guide for consultants to write consulting records, hoping to help everyone.
What is a consultation record?
Consultation record and consultation notes are two different ways to record the whole consultation process. Mainly from the following aspects to distinguish between consulting records and consulting notes:
1 What is the main record?
Consultation records have relatively fixed contents, such as the date, start and end time, consultation frequency and consultation form of each consultation (individual, group, family, etc.). ), clinical examination results, problems complained by visitors, evaluation of visitors' functions and symptoms, visitors' response to consultation, progress of consultation, crisis assessment, consultation scheme, consultant's signature and date, etc. Instead, it is the mood, assumptions and opinions of the consultant. There is no fixed format for consulting notes, and the consultant can record them according to his own needs. Even information that cannot appear in the consultation notes can appear in the consultation notes, such as the consultant's speculation, emotions, difficulties in consultation, problems that need supervision, etc., mainly to help the consultant better consult.
Who has the right to see it?
Consultation records are equivalent to "official" medical documents and are an important part of visitors' files. Other professionals (supervisors and psychiatrists), parties and their families (who can apply in writing), judges, lawyers and other authorized related persons can read this document. However, the consultation notes are served by the consultants themselves and can only be consulted by themselves. But both should strictly abide by the principle of confidentiality and be properly kept.
Does the consultant have to take notes?
Consultants should write notes after each consultation, but the requirements of consultation notes are relatively flexible, and consultants can freely choose whether to write or not.
Guide to Writing Consultation Records (2)
Why write consultation records?
As for the role and function of consultation records, I have already talked about it. Here I only list the main points and don't expand them one by one.
1 Help the counselor to reflect on the consultation process and describe the progress of the case.
This helps other professional helpers to understand the case and promote peer communication, such as psychiatrists, supervisors and referred consultants.
Protecting visitors and consultants, especially when it comes to moral and legal issues, can be used as evidence.
Consulting records are an important basis for the third party to choose to pay consulting fees.
Custody of consulting records
keep secret
Visitors' files must be kept in a locked cabinet in a locked room. Visitors have the right to ask to read the consultation records about themselves. Without the authorization of the visitor, it shall not be shared with individuals/groups outside the institution, except at the request of the judge, but the summons of lawyers is not within this scope.
In the visitor's file, the consultation record is stored in flashback time.
After the visitor closes the case, the time that the consultation record needs to be kept depends on local laws.
When writing the consultation record, I always imagine that one day, in court, the judge, both sides, including visitors, will read this record.
Guide to Writing Consultation Records (3)
Ethical norms related to consultation records
On July 1 day, 2065438, the second edition of the Ethical Code of Clinical and Counseling Psychology of Chinese Psychological Association was officially implemented. In the Code of Ethics, there are two main provisions about consultation records: what needs to be recorded and how to save and transmit the records.
1 What should I remember?
(1) Double relationship: For the inevitable multiple relationships in psychological counseling, psychologists need to make a good record to prevent possible influences (1. 1.7).
(2) Informed consent: Psychologists should carefully record the discussion about informed consent during evaluation, consultation or treatment (2.2. 1).
2 How to save and transmit the consultation records?
(1) Remote professional work: Psychologists should inform professional service seekers of the confidentiality restrictions of electronic records and remote service processes in network transmission, and inform professional service seekers whether relevant personnel (such as colleagues, supervisors, case managers and information technology personnel) can access these records and consultation processes. Psychologists should take reasonable preventive measures (such as setting user password, website password, consultation record document password, etc.). Ensure the security of information transmission and storage (8.8.2);
(2) Privacy and confidentiality: Psychologists should create, save, use, transmit and process information related to their professional work (such as case records, test materials, letters, audio recordings, video recordings and other materials) in strict confidentiality in accordance with laws, regulations and professional ethics. Psychologists can tell those who seek professional services how to keep case records, and whether relevant personnel (such as colleagues, supervisors, case managers and information technology personnel) can access these records and other information (3.3.4).
Guide to Writing Consultation Records (4)
What principles should be followed in writing consultation records?
The writing of consultation records mainly follows the following principles:
1 Confidentiality: The contents and storage of records shall be kept as confidential as possible. The third person should be used, visitors can be addressed by code names, and case information that can be recognized by a third party should not be included.
Relevance: only record the contents related to the consultation case and consultation process, and avoid writing irrelevant information, such as the names of third parties mentioned by visitors.
Objectivity: record the counselor's objective observation of the physical and mental state of the visitors, and write clearly who said this sentence. If it is described in the language of the visitor, it needs to be quoted to avoid subjective assumptions and absolute terms.
Conciseness: try to summarize the key contents of the consultation with the least number of words, use accurate words and write the contents of the same topic together. (Moral Code 3.3: "Psychologists are obliged to abide by laws and regulations and disclose relevant information according to the minimum principle …").
5 Professionalism: record which services are used and whether they meet the professional specifications.
Guide to Writing Consultation Records (5)
There are many common templates for writing consultation records.
Here are six consultation record templates for you to choose from.
1SOAP record
S (subjective): Describe the symptoms complained or reported by visitors.
O (objective): the consultant's observation, test results and physiological examination results.
A (evaluation): the consultant's evaluation of the visitors' questions and the consultation process, the effect of the current talks and the whole consultation, the achievement of the consultation objectives, and the places where more work needs to be done.
P (plan): consultation plan and follow-up consultation plan, such as homework, time and arrangement of the next meeting, change of consultation plan, etc.
2DAP record
D (data): the collection of subjective and objective data about visitors, such as what happened in consultation, what was said, visitors' complaints, clinical observation, intervention and evaluation results.
A (evaluation): the consultant's evaluation of the visitors' questions and the consultation process, the effect of the current talks and the whole consultation, the achievement of the consultation objectives, and the places where more work needs to be done.
P (plan): consultation plan and follow-up consultation plan, such as homework, time and arrangement of the next meeting, change of consultation plan, etc.
3BIRP record
B (behavior): observation of problems and behaviors, including duration, severity, frequency, etc.
I (intervention): the actions taken by the consultant in the consultation process, such as challenges, support, feedback, etc.
R (response): the response of visitors to the intervention.
P (plan): consultation plan and follow-up consultation plan, such as homework, time and arrangement of the next meeting, change of consultation plan, etc.
Guide to Writing Consultation Records (6)
4PAIP record
P (Question): Tourists' description of their own problems.
A (evaluation): the consultant's evaluation of the visitors' questions and the consultation process, the effect of the current talks and the whole consultation, the achievement of the consultation objectives, and the places where more work needs to be done.
I (intervention): the actions taken by the consultant in the consultation process, such as challenges, support, feedback, etc.
P (plan): consultation plan and follow-up consultation plan, such as homework, time and arrangement of the next meeting, change of consultation plan, etc.
5GIRP record
G (objective): the consulting objectives and complaints of visitors.
I (intervention): the actions taken by the consultant in the consultation process, such as challenges, support, feedback, etc.
R (response): the response of visitors to intervention;
P (plan): consultation plan and follow-up consultation plan, such as homework, time and arrangement of the next meeting, change of consultation plan, etc.
6HIPAA general record
(1) Basic information: number of visitors, date, starting and ending time, consultation time (minutes), etc.
(2) symptom change and intervention;
(3) visitors' response to the intervention;
(4) crisis situation assessment;
(5) consultation plan;
(6) Supervision, expert advice and peer exchange;
(7) The signature and date of the consultant;
After careful study of the above templates, it is found that there is little difference between each template, which is generally consistent with the process and stage of consultation. Therefore, I suggest you choose 1-2 template according to your own preferences and practice it deliberately, and you will soon master the method of writing consultation records.
Guide to Writing Consultation Records (7)
The content of the progress statement.
Name of the visitor
Start and end time and date of consultation
Counseling frequency and mode, psychometric related results
Discussion on visitors' rights such as confidentiality clause
Major complaints, crisis assessment
Important topics of this consultation
Consultation progress and objectives
Consultant's observation and treatment
Signature, educational background and date of other service consultants recommended by consultants.
Contents of consultation notes (psychological notes)
Consultant's hypothesis, speculation
Counselors' feelings, thoughts, reactions and judgments on visitors in consultation.
Counselors' reflection on consultation and difficulties encountered in consultation \
I want to ask the supervisor's question
Supervise middle school
The difference between consultation records and consultation records
The readers of the consultation records are all the individuals mentioned above. The reader of the consultation note is the consultant himself.
The consultation record is part of the visitor's file. Consulting notes are not.
Guide to Writing Consultation Records (8)
The following contents should not appear in the consultation record.
Counselors' Emotions, Thoughts and Reactions in Consultation
The consultant's hypothesis is to think about various possibilities when the concept is personalized.
Information unrelated to treatment
A detailed record of visitors' criticism of other service providers.
No other people involved in interventional therapy can identify their own information.
Information beyond the consultant's ability
When will the consultation record be completed?
Within 24 hours after the consultation, and sign the date.
Don't leave blank in the text.
Consultation records shall not be modified invisibly.
You can write the modified content with strokes, and then sign the date on the modified part.
When the visitor does not come, or cancels, it should also be recorded that the visitor does not come.
Explain the reason for not coming.
And whether the counselor tried to make an appointment with the visitor for the next consultation.
As promised, when is the next consultation?
Guide to Writing Consultation Records (9)
What are the precautions for writing consultation records?
1 Every consultation should be recorded, preferably completed within 24 hours after consultation, signed and dated.
Check grammar mistakes to make sure the words are accurate and unambiguous.
Besides the general abbreviations, use abbreviations as little as possible.
If there is any mistake in the record, draw a horizontal line directly in the wrong place, mark "Error" next to it, sign and indicate the date of revision, and don't scribble on a large scale.
5 Each record is immediately followed by the previous record, and there are no spaces in the text.
Each page of the record needs to have the case number of the visitor.
7 abide by the five principles of writing consultation records.
Each consultation record needs the signature and date of the consultant.
If the visitor fails to come or is cancelled temporarily, the consultant also needs to explain the reasons for his failure to come and whether the consultant (or assistant) has tried to make an appointment with the visitor for the next consultation. If yes, please indicate the time of the next consultation.
10 ensures the storage and transmission security of consulting records. As Kettenbach( 1995) said, "Writing consultation records is not only something that consultants should do well, but also something that every consultant must do well." The quality of consultation records largely represents the quality of service that consultants can provide. Just like other consulting skills, the ability to write consulting records needs deliberate practice.
I hope this necessary guide to writing consultation records will help you, and I wish you further and further on the road of helping others.
Guidelines for writing consultation records (10)
Example of consultation record 1
* This case is pure fiction *
The visitor is a female freshman, dressed casually and neatly, and behaved appropriately. The chief complaint is that her parents decided to divorce. Three days ago, she had an "emotional breakdown" and came to consult in the hope of relieving stress. Visitors have fluent language, moderate speech speed and clear thinking. She described in detail the state of her parents on the day of their divorce, including crying, fear and inability to eat. And then took a deep breath. The counselor stays focused and listens, and explores her state in an acceptable way. Through the restatement, emotional reaction and open-ended questions of the psychological counselor, the visitors realized that their emotional collapse came from the belief that "my parents divorced and I became a child without a family".
On the one hand, psychological counselors affirm that it is normal for visitors to feel sad because of their parents' divorce, on the other hand, they encourage visitors to rebuild their beliefs about how their parents' divorce affects them. With the help of the counselor, the visitor changed his belief to "Although there is no love between my parents, their love for me will not decrease." . I need some time to adapt to this new family structure. "After the feedback from visitors replaced the old beliefs with new ones, they were still very sad, but they could bear it.
The consultant assigned homework to the visitors and asked them to continue to practice replacing the old beliefs with new ones. In the next consultation, counselors and visitors will continue to devote themselves to the beliefs of visitors.