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MODELO HISTORIA CLÍNICA PSICOLÓGICA espaciada

MODELO HISTORIA CLÍNICA PSICOLÓGICA espaciada

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HISTORIA CLÍNICA PSICOLÓGICA.

ANAMNESIS
I. Datos de Filiación
• No!. " A#ell.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Se%o ____________ Edad$$$$$$$$$$$ Fec&a de Nac.$$$$$$$$$$$$$$$$$$$
• L'(a) de Nac.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ P)ocedencia$$$$$$$
• Di)ección ______________________________________ T*l+________________________
• G)ado de Inst.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Reli(ión$$$$$$$$$$$$$$$
• Estado Ci,il ______________________________ Oc'#ación$$$$$$$$$$$$$$$$$$$$$$$$$
• Pad)e __________________________________________ Edad____________________
• Mad)e __________________________________________ Edad____________________
• Re+e)ente ______________________________________________________________________
• In+o)!antes ______________________________________________________________________
• L'(a) de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Fec&as de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• E%a!inado) Psicólogo Jorge Luis Fernández Salguero.
II. Moti,o de Cons'lta
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III. Histo)ia de la En+e)!edad o del #)o-le!a act'al
A. Tie!#o
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.. Fo)!a de Inicio
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C. S/nto!as P)inci#ales
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D.Relato
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E. Antecedentes Cl/nicos
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I0. Antecedentes Pe)sonales
A. Eta#a P)e1natal 2E!-a)a3o o (estación4
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.. Eta#a Natal 2Pa)to4
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C. Eta#a Post1Natal
 P)i!e) A5o
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 Desa))ollo Ne')o1Psico!oto)
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D.Ras(os Ne')o#6ticos
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E. Eta#a Escola)
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F. Desa))ollo " F'nción Se%'al
 As#ectos Fisioló(icos 7Se%o !asc'lino. Se%o Fe!enino8
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 As#ecto #sicose%'al " Mat)i!onio
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G.Acti,idad La-o)al
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H.Se),icio Milita)
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I. Reli(ión
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9. H6-itos e in+l'encias noci,as o tó%icas
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:. Histo)ia de la Rec)eación " de la ,ida
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L. En+e)!edades " accidentes
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M. Pe)sonalidad P)e!ó)-ida
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0. Antecedentes Fa!ilia)es
A. Co!#osición Fa!ilia)
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.. Din6!ica Fa!ilia) 7H6-itos; cost'!-)es8
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C. Condición Socioeconó!ica 7,i,ienda; condiciones sanita)ias; '-icación
socioc'lt')al; oc'#ación8
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D.Antecedentes Patoló(icos
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0I. Res'!en
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E<=MEN PSICOLÓGICO O MENTAL
I. Datos de Filiación
• No!. " A#ell.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Se%o ____________ Edad$$$$$$$$$$$ Fec&a de Nac.$$$$$$$$$$$$$$$$$$$
• L'(a) de Nac.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ P)ocedencia$$$$$$$
• Di)ección ______________________________________ T*l+________________________
• G)ado de Inst.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Reli(ión$$$$$$$$$$$$$$$
• Estado Ci,il ______________________________ Oc'#ación$$$$$$$$$$$$$$$$$$$$$$$$$
• Pad)e __________________________________________ Edad____________________
• Mad)e __________________________________________ Edad____________________
• Re+e)ente ______________________________________________________________________
• In+o)!antes ______________________________________________________________________
• L'(a) de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Fec&as de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• E%a!inado) Psicólogo Jorge Luis Fernández Salguero.
II. Actit'd Po)te " Co!#o)ta!iento
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III. Atención; Conciencia " O)ientación
Atención " Concent)ación
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Conciencia o Estado de Ale)ta
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O)ientación 7Tie!#o; es#acio; l'(a); #e)sona " #e)sonas8.
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I0. Len('a>e 7Rit!o; tono; contenido8
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0. Pensa!iento 7C')so " contenido8
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0I. Pe)ce#ción
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0II.Me!o)ia 7Co)to " la)(o #la3o8
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0III. F'nciona!iento Intelect'al
Conoci!ientos Gene)ales.
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Me!o)ia.
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Pensa!iento Ra3ona!iento " 9'icios
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I<. Estado de =ni!o " A+ectos
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<. Co!#)ensión " G)ado de Inca#acidad del P)o-le!a o En+e)!edad
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<I. Res'!en
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INFORME PSICOM?TRICO.
I. Datos de Filiación
• No!. " A#ell.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Se%o ____________ Edad$$$$$$$$$$$ Fec&a de Nac.$$$$$$$$$$$$$$$$$$$
• L'(a) de Nac.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ P)ocedencia$$$$$$$
• Di)ección ______________________________________ T*l+________________________
• G)ado de Inst.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Reli(ión$$$$$$$$$$$$$$$
• Estado Ci,il ______________________________ Oc'#ación$$$$$$$$$$$$$$$$$$$$$$$$$
• Pad)e __________________________________________ Edad____________________
• Mad)e __________________________________________ Edad____________________
• Re+e)ente ______________________________________________________________________
• In+o)!antes ______________________________________________________________________
• L'(a) de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Fec&as de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• E%a!inado) Psicólogo Jorge Luis Fernández Salguero.
II. O-se),aciones Gene)ales
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III. Inst)'!entos @tili3ados
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I0. Inte)#)etación de los inst)'!entos
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0. Res'!en
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Fe)n6nde3 Sal('e)o 9o)(e
L'is
Psicólo(o
C.Ps.P. ABCBC
INFORME PSICOLÓGICO
I. Datos De Filiación
• No!. " A#ell.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Se%o ____________ Edad$$$$$$$$$$$ Fec&a de Nac.$$$$$$$$$$$$$$$$$$$
• L'(a) de Nac.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ P)ocedencia$$$$$$$
• Di)ección ______________________________________ T*l+________________________
• G)ado de Inst.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Reli(ión$$$$$$$$$$$$$$$
• Estado Ci,il ______________________________ Oc'#ación$$$$$$$$$$$$$$$$$$$$$$$$$
• Pad)e __________________________________________ Edad____________________
• Mad)e __________________________________________ Edad____________________
• Re+e)ente ______________________________________________________________________
• In+o)!antes ______________________________________________________________________
• L'(a) de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Fec&as de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• E%a!inado) Psicólogo Jorge Luis Fernández Salguero.
II. Moti,o de Cons'lta
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III. T*cnicas e inst)'!entos @tili3ados
ψ Observación.
ψ Entrevista.
ψ Historia Clínica.
ψ Pruebas Psico!tricas
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I0. Antecedentes Pe)sonales " Fa!ilia)es
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0. O-se),aciones Cond'ct'ales.
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0I. An6lisis e Inte)#)etación de los Res'ltados.
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0II.Dia(nóstico o Concl'sión.
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0III. P)onóstico.
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I<. Reco!endaciones
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ψ
PLAN PSICOTERAPEDTICO
I. Datos de Filiación
• No!. " A#ell.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Se%o ____________ Edad$$$$$$$$$$$ Fec&a de Nac.$$$$$$$$$$$$$$
• L'(a) de Nac.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ P)ocedencia$$
• Di)ección ______________________________________ T*l+___________________
• G)ado de Inst.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Reli(ión$$$$$$$$$$
• Estado Ci,il ______________________________ Oc'#ación$$$$$$$$$$$$$$$$$$$$
• Pad)e __________________________________________ Edad_______________
• Mad)e __________________________________________ Edad_______________
• Re+e)ente _________________________________________________________________
• In+o)!antes _________________________________________________________________
• L'(a) de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• Fec&as de E,al.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
• E%a!inado) Psicólogo Jorge Luis Fernández Salguero.
II. Dia(nóstico Psicoló(ico
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III. O->eti,os Gene)ales
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I0. O->eti,os Es#ec/+icos
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0. T*cnicas Te)a#*'ticas
ψ
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SESIÓ
N
T?CNICAS REALIEADAS
P
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O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
S
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O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
T
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O->eti,os Acciones Es#eci+icas
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VI. Actividades Psicoterapéuticas:
SESIÓ
N
T?CNICAS REALIEADAS
C
@
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O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
F
@
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N
T
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O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
S
E
<
T
A
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O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
S
E
P
T
I
M
A
“ ”
O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
O
C
T
A
0
A
“ ”
O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
N
O
0
E
N
A
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O->eti,os Acciones Es#eci+icas
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SESIÓ
N
T?CNICAS REALIEADAS
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0II. Tie!#o de E>ec'ción
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0III. A,ances " Lo()os Te)a#*'ticos
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
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A)eG'i#a de del CHAH

Antecedentes Personales: A.____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ E. Etapa Post-Natal:  Primer Año: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________  Desarrollo Neuro-Psicomotor: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ . Antecedentes Clínicos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ IV. Etapa Natal: “Parto” ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C. Etapa Pre-natal: “Embarazo o gestación” ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B.

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