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Historia clinica Ejemplo
Psicología Aplicada I. Clinica Y De La Salud (Universidad Antonio Nariño)
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HISTORIA CLÍNICA
Fecha de atención
Fecha de recepción
Numero de Historia Clínica
CIE10:
Categorización CAP:
I. DATOS DEL CONSULTANTE
Nombres y apellidos:
Tipo de documento: CC
Teléfono:
CE
Nº
Parentesco:
Sexo:
F
M
Sexo:
F
M
Años
II. DATOS DEL PACIENTE
Nombres y apellidos:
Tipo de documento: CC TI RC CE
N°
Fecha de Nacimiento:
Lugar nacimiento:
Estado civil:
Procedente de:
Escolaridad:
Profesión:
Dirección:
Localidad:
N°
Estrato:
Email:
EPSS.
EPSC.
Institución:
Viene remitido:
Si No
Fecha de la remisión:
Institución que remite:
Profesional que remite:
I.
Edad:
Religión:
Ocupación:
Barrio:
Teléfonos:
Motivo de consulta
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II.
Problemática actual
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III.
Historia Personal
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IV.
Antecedentes (Médicos, psicológicos, psiquiátricos y otros relacionados)
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V.
Estrategias de evaluación
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Pruebas psicométricas ____ Cuál? ___________________________________________________________________________________________________
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Cuestionarios ____ Cuál? _________________________________________________________________________________________________________
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Pruebas Proyectivas ____ Cual? ____________________________________________________________________________________________________
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Examen Mental___
Entrevistas ___
VI.
Resultados de evaluación
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VII.
Historia Familiar (Relaciones familiares y Eventos significativos)
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VIII.
Genograma
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IX.
Hipótesis Psicológicas
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X.
Objetivos terapéuticos
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XI. Estrategias y Técnicas Terapéuticas
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XII.
Logros alcanzados con base en los objetivos terapéuticos
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XIII.
Logros alcanzados según el consultante
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XIV.
Resumen
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XV.
Remisiones
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XVI.
Observaciones y Recomendaciones
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Estudiante Practicante: __________________________________________
Docente Asistencial: _______________________________________________
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