Medical history: what aspects to include?

The medical history is a document prepared by the therapist that collects different aspects of a client’s therapy. It begins with the first visit, includes the patient’s evaluation, the subsequent evolution in therapy and finally the follow-up after the intervention.

Each therapist has their own way of constructing a clinical history since it is a personal document; If something has to be given to the client, as proof or marker of therapy, a psychological report will be prepared. corresponding, but the stories will not be transferred.

Therefore, medical histories can be made freely. However, and given that it is a very useful psychological tool for the therapist, they are presented a series of recommendations that can allow us to get the most out of a document that can be decisive in the development of therapy.

What is a medical history for?

A client’s medical history allows you to organize all the information received in session. From the first evaluation, the relevant aspects of the individual’s speech and everything worked on in the session are noted. It is therefore a tool that allows you to shape data that often comes quickly and in large quantities.

Subsequently, everything collected in the medical records will be great value to perform the complete functional analysis, because with the support they provide it is possible to include everything and not forget any relevant data. Before our clients’ sessions, and taking into account the volume of patients in an office, it is possible that reading the medical history is very useful to refresh what is being worked on, how it is being done and the improvements and difficulties that are observed.

Relevant aspects to include from the evaluation

Some relevant aspects to include would be

Division by areas: Surely the evaluation will talk about very different topics. Therefore, it is recommended that before taking the clinical history, different problem areas -For example, family area, social area, mood area — to make it more accessible to read. Furthermore, by organizing it in this way, it is very likely that the objectives to be worked on in session and the functional analysis will be organized according to these areas.Relevant information from past events: It is not necessary to capture the individual’s past with a multitude of details. It is relevant that the first clinical records contain past information, from their social and/or family history to their psychopathological course, but those aspects that are interesting for the therapist.Session information: when we already know the client’s personal history and it has been captured in the first clinical histories, it is recommended that the following ones be about what happened during the client’s weekthe difficulties you have had, the emotions you have not known how to control, what has been done in sessionwhat techniques have been used…Client tasks: It is very interesting to include a section of tasks that the client has to perform for the following week, not only the written ones – such as making a self-record or writing down irrational thoughts – but also the recommendations that have been given in session – for example, if The curve of emotions has been explained to you, one of your tasks may also be to stop doing certain activities at the peak of that curve.Therapist tasks: it is recommended to include after the narrative of the session and the client’s week and the tasks for the following week a section of tasks that we therapists have to do in the next session. The tasks can range from reviewing the irrational thoughts that the client will have written down and restructuring at least three, asking about self-harm or evaluating the client’s social area; to preparing progressive muscle relaxation or bringing a whiteboard to work on social skills with a child. The therapist’s tasks constitute what the therapist himself wants to include, relevant to the next session.Functional sequences: within the cognitive-behavioral model, prior to developing therapy objectives, a functional analysis of the individual’s behaviors is carried out, which can elucidate which elements of the sequence to change. The functional analysis can be concluded (and sometimes not even) at the end of the evaluation. However, it is recommended to include a small functional analysis section in each of the medical records to build the sequences as they are observed in session, and not wait to have the evaluation finished. They can be modified later.

Medical records are also for other professionals

Preparing competent clinical histories is also relevant for “intrapsychological communication.”. If at any time the therapist is unable to continue with the treatment, the individual changes city and needs to attend another clinic, or the therapist simply changes, it is essential to give them the information obtained so that they can continue working with the client.

Stories make up this transfer of information. For this reason, certain recommendations are included that will make the medical history a bridge that facilitates the change of therapist and guarantees consistent treatment:

clinical eye: It is not only necessary to capture the information that is communicated to us exactly as it comes. It is relevant to write down our impressions that include other details, such as non-verbal communication. The clinical eye is related to what the therapist sees in addition to what the client tells, and those notes could be very useful to another therapist who reads our stories. Therefore, we should not be afraid to include ideas that we have not yet confirmed. These may be useful or corrected later.Treatment plan and techniques: when the evaluation is completed and all the necessary information is available, it can be included at the beginning of the compilation of all weekly medical records a section of objectives for therapy; for example, “Provide Clara with basic social skills and ensure that she is able to feel comfortable in interaction contexts.” Once the objective has been stated, it is advisable to write next to it the techniques that will be used to achieve it; for example, cognitive restructuring, modeling, exposure with response prevention. All the objectives that the client wants to achieve and the therapist can offer can be proposed.

Finally, we must remember that the medical history is a document that contains a lot of information about the client, so of course names or surnames will never appear, and data such as place of residence or age can be changed so that this medical history is as impersonal as possible in the event that it is lost. It is recommended to store the stories in the cabinet and try to remove them from the workplace as little as possibleas well as encrypting documents if they have to be sent over the network.

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