1. Principles of writing case records
1. Third person writing is required.
2. The content should be concise and to the point.
3. adopt the orientation of facts and symptoms.
4. avoid writing important information of others.
5. indicate the source of information appropriately.
6. Length: 5.6 lines on A4 paper. (The more detailed the record, the greater the possibility and risk of privacy exposure. )
Second, the reference format
Different genres have different recording focuses.
1. Focus consultation (case information, chief complaint, objectives, resources, one small step, consultation thinking)
2. Reference format
(1) Example of general case records
The 1th consultation on April 15, 28.
Talk about the case on time, complain about interpersonal troubles, help the case explore the possible causes of people's troubles, provide role-playing exercises, and encourage individuals to be aware of their possible shortcomings. The feelings of individual cases and important people are also the focus of this interview. Encourage individual cases to develop the habit of being aware of their words and deeds at any time. It is suggested that the case continue to be discussed.
consultant's signature:
(2)SOAP case record example
The fifth psychological consultation on May 21, 28
S: Subjective
The client has to live very tired, and he has to endure his parents' quarrels all day when he goes home on holiday. When he returns to Taipei, he feels uneasy and guilty, and he doesn't know why he has been in a bad mood.
: objective
The parties come to the interview on time, anxious and exhausted, eager to clarify their difficulties and concerns, hoping to get better soon.
A: Assessment
The parties' worries and anxieties have slightly improved, but the parties have obvious strict self-requirements, which easily lead to anxiety and guilt.
P: Plan
to carry out weekly psychological counseling, provide comprehensible psychological counseling, help clients to detect the possible root causes behind anxiety and guilt, and learn to relax strict demands on themselves.
signature of consultant: