CENTRO DE ATENCIÓN INTEGRAL A LA FAMILIA SANTA ROSA DE LIMA

HISTORIA CLINICA
ADULTO
NOMBRE DEL TERAPEUTA RESPONSABLE:
NUMERO DE CONTACTO:
CORREO ELECTRONICO:
FECHA DE ELABORACION DE HISTORIA:
IDENTIFICACION DE PACIENTE
NOMBRE:
EDAD: FECHA DE NACIMIENTO:
SEXO: ESCOLARIDAD:
ESTADO CIVIL: EPS:
DIRECCIÓN:
TELEFONOS:
REMITIDO POR:
MOTIVO DE CONSULTA: (textual, fecha aparición, momentos inicio, factores predisponentes y desencadenantes).
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INICIO Y CURSO (DESCRIPCIÓN DE SINTOMAS QUE PRESENTA EL PACIENTE)

EPISODIOS PREVIOS:
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TIEMPO DEL PROBLEMA:
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FACTORES DESENCADENANTES DEL PROBLEMA ACTUAL (agravantes y repercusión en su vida social,

riesgos para sí o los demás):
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ANTESCEDENTES FAMILIARES (trastornos mentales u orgánicos, conductas delictivas, etc.).

FAMILIARES:
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PERSONALES:
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OTROS:
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SUMARIO DIAGNOSTICO –RESULTADOS DE EXAMEN – TRATAMIENTO Y EVOLUCION

1. SUMARIO DIAGNOSTICO
APROXIMACION DIAGNOSTICA
(Hipótesis diagnostica)

2. EVALUACION PSICOLOGICA
BATERIAS APLICADAS:
NOMBRE DE LA PRUEBA FECHA DE APLICACIÓN

SINTESIS DE LOS HALLAZGOS (ANALISIS DE RESULTADOS):

CONCLUSION DIAGNOSTICA:

IMPRESIÓN DIAGNOSTICA (CIE – 10):

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CODIGO NOMBRE

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FIRMA DEL TERAPEUTA
NOMBRE :_______________________________________
T.P. _________________________________________

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FIRMA DEL COORDINADOR
COMENTARIOS ADICIONALES
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Nota: Todos los apartes de la historia deben estar completos. En dado caso que no se cuente con
información se debe colocar SDI, esto quiere decir Sin Datos de Importancia
 CENTRO DE ATENCIÓN INTEGRAL A LA FAMILIA SANTA ROSA DE LIMA
REGISTRO DE PRIMERA/UNICA SESION
RESUMEN DE LA SESION
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EXPECTATIVAS DEL CONSULTANTE

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HIPOTESIS INICIAL
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OBSERVACIONES PERTINENTES
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Terapeuta a Cargo
 CENTRO DE ATENCIÓN INTEGRAL A LA FAMILIA SANTA ROSA DE LIMA
EVOLUCION POR SESION
RESUMEN DE LA SESION
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OBSERVACIONES PERTINENTES
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Terapeuta a Cargo

(tiene que ser una hoja por resumen de sesion)

 CENTRO DE ATENCIÓN INTEGRAL A LA FAMILIA SANTA ROSA DE LIMA
CIERRE DE PROCESO TERAPEUTICO
MOTIVO DE TERMINACION DEL PROCESO
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RESUMEN DEL CASO

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ALCANCES TERAPEUTICOS
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AUTOEVALUACION DEL CONSULTANTE
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OBSERVACIONES Y RECOMENDACIONES
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Terapeuta a Cargo