The psychological record is an important

Source of records about the care given to a patient. In addition to informing about the evolution in treatment , the document gathers essential data for the assistance provided by multidisciplinary teams. Hence the need for it to be organized, contemplate the basic structure described in the legislation and be understood by different health professionals. I present tips for preparing and updating the psychological record throughout this article. You will even know the advantages of the online medical record in relation to the conventional one.

What is a psychological record

Psychological record is the document that gathers the main information about psychological assistance , such as the technical-scientific procedures adopted. Often, it corresponds to the complete documentary record of the consultations, with Canada Mobile Number List details about the patient’s health history. However, there are situations in which the medical record presents only the data strictly necessary for the work of a multidisciplinary team , Thus, it becomes an abridged version. In these cases, it is up to the psychologist to keep a documentary record separate from the medical record, as determined by Resolution CFP . The legislation made it mandatory.

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The documentary record on the provision

Of psychological services that cannot be kept primarily in the form of a psychological record. For reasons that involve restricting the sharing of information with the user and or beneficiary of the service provided. The documentary record on . Paper or computerized is confidential and constitutes a set of information that aims to briefly contemplate Gmxemail List the work performed. The description and evolution of the activity and the technical-scientific procedures adopted”. What is the psychological record for? The psychological record serves as a historical record of therapy sessions and other services provided by the psychologist. To do so, it combines patient identification data and the professional responsible for describing the evolution of the work. Having this document is important to monitor the results.

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