Medical Record: Which Aspects To Include?

The medical file is a document drawn up by the therapist which covers different aspects of a patient’s therapy. It is started on the first visit; it resumes the assessment of the patient, his subsequent evolution in therapy and, finally, the follow-up after the intervention.

Each therapist has their own way of building a medical record because it is a personal document. If something needs to be given to the patient, such as a receipt or proof of therapy, he will write a corresponding psychological report but will not hand over the medical file.

This file can therefore be done freely. Nevertheless, and since this is a very useful psychological tool for the therapist, a series of recommendations should be followed  . These will allow us to derive the greatest benefit from a document that can be decisive in the course of the therapy.

What is a medical record for?

The medical file of a patient makes it possible to organize all the information that one receives during a session. From the first assessment, we note the relevant aspects of the individual’s speech and everything we work on in therapy. It is, therefore, a tool that allows to give shape to many data often evoked quickly.

After that, everything that has been included in the medical file will be of great value for carrying out a full functional analysis. This is because the support of the information makes it possible to include everything and not to forget any important data.

Before the sessions of our patients, and taking into account the number of patients in an office, it is possible that reading the medical file is of great use to remember what we are working on, how the session takes place as well as the improvements and difficulties that we observe.

Important aspects to include in the assessment

We can cite several relevant aspects to include. Among them are the following:

• Division by areas: during the evaluation, very distinct themes will surely be addressed. Therefore, before carrying out the medical file, it is recommended to identify different problem areas – for example, the family domain, the social domain, the mood domain – so that its reading is more accessible.
  • By organizing it this way, it is likely that the objectives to be worked on during the session and the functional analysis are also organized according to these areas.

• Relevant information from past events:  It is not necessary to enter the individual’s past in a great deal of detail. In the first medical files, it is important that one inscribes the past information, social and / or family antecedents with their psychopathological evolution, but only those aspects which are interesting for the therapist.
• Information about the session: Once we know the patient’s personal history and it has been recorded in the first medical records, it is recommended that subsequent ones look at what happened during the session. week of the patient, the difficulties he encountered, the emotions he could not control, what was worked on during the session, the techniques that were used …

• Patient exercises:  It is very interesting to include a part of the exercises that the patient has to do for the following week, not only the written exercises – like keeping a journal or noting his irrational thoughts – but also the recommendations that he has been given. – for example, if the emotion curve has been explained to him, one of his exercises may be to stop doing certain activities when he is at the top of this curve.
• Therapist Exercises: It is recommended that you include a list of exercise therapists should do in the subsequent session.
  • It may involve evaluating the irrational thoughts that the client will have noted, restructuring at least three of them, questioning him about the harm he could have done, assessing the patient’s social domain, preparing progressive muscle relaxation or bring a slate to work on social skills with a child.
• Functional sequences:  in the cognitive and behavioral model, before the development of the therapy objectives, a functional analysis of the individual’s behaviors is carried out, which can establish the elements of the sequence to be changed. The functional analysis can be considered complete (but not always) at the end of the assessment.
  • It is recommended to include a small part of functional analysis in each medical file to gradually build the sequences as they are studied during the sessions, and not to wait to complete the evaluation. Changes are always possible.

Medical records are also used by other professionals

Developing relevant medical records is important for “intrapsychological communication”. If the therapist is unable to continue treatment or if the individual moves and needs to see another therapist, it is essential to provide the new therapist with the information obtained so that they can continue to work with the patient.

The medical records contain all the information about the therapy. This is why we include certain recommendations that will make this medical file a bridge allowing the change of therapist and guaranteeing consistent treatment :

• Clinical point of view:  it is not only necessary to record the information that is communicated to us directly; we must also note our impressions, which can include other details such as non-verbal communication.
  • The clinical perspective is related to what the therapist sees beyond what the patient tells, and these notes can be of great help to any other therapist. So we should not be afraid to include ideas that we have not yet confirmed. These can be helpful or corrected later.
• Treatment plan and techniques:  Once the assessment is complete and all the necessary information is available, an objective section for therapy can be included at the start of all weekly medical records. For example, “providing Claire with basic social skills so that she can feel comfortable in contexts of interaction”.
  • Once this objective has been established, it is recommended to write, alongside, the techniques that will be used to achieve it. For example, cognitive restructuring, modeling, exposure with response prevention. All the goals that the patient wants to achieve and that the therapist can offer can be entered.

Finally, it should be remembered that the medical record is a document that contains a lot of information about the client. Consequently,  we will never enter first names or surnames and we can even change data such as place of residence or age so that this file is as impersonal as possible if it were to be lost.

It is recommended that you store medical records in the office and try to remove them from the workplace as little as possible, as well as encrypt documents if they need to be sent online. To remember.

Our thoughts

Psychologists can have the same facilities and difficulties as anyone else. That is why they are also undergoing therapy.