Psychologist: documents, journals, diaries, reports

Clinical and medical psychologist of health care institutions and other enterprises, in their practical activities, one way or another, use different types of documents for ordering the work and its proper organization.

In the previous article we considered the basic legal documents of a psychologist, but here I will reveal to you what you really will need in practical work with the client. In parallel, you can download the attached documents in doc format on your computer and apply them in your work.

Any activity, as we know, must begin with an order on the main activity in the institution, so we will begin with it.

Order: sample sample

Thisthe order on approval of the Regulations on the activity of the clinical / medical psychologist and the maintenance of accounting reporting forms of documentation, The example of such an order.

State budgetary health care institution "Name central district hospital" stanitsa Name

ORDER

of February 17, 2017 No. 128 A "On approval of the Regulations on the activity of the clinical / medical * psychologist GBUZ" Name of CRH "and maintenance of accounting and reporting forms of documentation of a medical psychologist"

In order to increase the effectiveness of the activity of the State Institution of Higher Education "CRH Name"

ORDER:

1. Approve:

1.1.Regulations on the activities of the clinical / medical psychologist GBUZ "CRH Name", in accordance with Annex 1( 2 pages).

1.2.Form "Consent of the client for the processing of personal data" for the work of a clinical / medical psychologist, according to Appendix 2( on 1 page).

1.3.The form "The Journal of Citizens' Appeal to the Clinical / Medical Psychologist of the State Health Care Institution" Name of the CRH ", for fixing the data of citizens applying to a clinical / medical psychologist, according to Appendix 3( 1 page).

1.4.The form "Coding of the client's personal data in the activity of the clinical / medical psychologist of the State Health Insurance Fund" CRH Name ", in order to improve the conditions for the anonymity of applications and the confidentiality of customer information, in accordance with Appendix 4( 11 pages).

1.5.The individual psychological card of the client of the clinical / medical psychologist of the State Clinical Hospital "CRH Name" for recording information about the client, the dynamics of his condition and the psychodiagnostic, psycho-consultative and psychocorrectional measures performed, according to Appendix 5( 2 pages).

1.6.The form "Journal of the consultative work of the clinical / medical psychologist GBUZ" CRH Name "for fixing psychological counseling, according to Appendix 6( on 1 page)

1.7.The form "Journal of the psychodiagnostic work of the clinical / medical psychologist of the Leningrad Regional Clinical Hospital" CRH Name "for fixing psychodiagnostic measures, according to Appendix 7( on 1 page).

1.8.The form "Diary of the individual psycho-correctional work of the clinical / medical psychologist GBUZ" CRH Name "for fixing psycho-corrective measures, according to Appendix 8( on 1 page).

1.9.Form "Diary of the group psycho-corrective work of the clinical / medical psychologist GBUZ" CRH Name "for fixing psycho-corrective measures when working with a group of clients, according to Appendix 9( on 1 page).

1.10.The form "Report on the activity of the clinical / medical psychologist of the State Health Insurance Fund" Name of the CRH "for maintaining monthly reports, according to Appendix 10( on 1 page).

1.11.Requirements to the experimental psychological examination and psychodiagnostic conclusions in the activity of the clinical / medical psychologist of the State Health Care Institution "Name of the CRH" and the standards of psycho-corrective work, according to Appendix 11( on page 4)

1.12.The procedure for registering a referral to the clinical psychological / medical examination of the clinical / medical psychologist of the State Health and Social Care Institution "Name of the CRH", according to Appendix 12( on 1 page)

1. Control over the execution of the order is assigned to the deputy head physician for the medical unit. Surname IO

Chief physician ANDO. Surname

I was acquainted with the order: Surname IO

* Note: from the wording type "clinical / medical" choose so that it corresponds to your staffing schedule in the organization with the names of posts. Further I will use these formulations as words of synonyms.

Regulations on the activities of the clinical psychologist HBUZ "Name of the CRH", goes, as you already understood in Appendix 1 to the order of the head doctor of the State Health Care Institution "The name of the CRH" dated February 17, 2017 No. 128-A and is on the page "Psychologist:and job description ".Here we will not consider it separately.

You can download the sample of the order here: Order No. 128 A dated 17.02.2017.

Consent of the client for the processing of personal data

Appendix 2 to the order of the Chief Medical Officer of the Central Bank of the Kyrgyz Republic "Name of the Central Bank of Russia"

Title: "Consent of the client for the processing of personal data"

I, __________( f.), Residing at:_________

_____________________________________,

( the name of the identity document, by whom and when issued)

in accordance with the requirements of Article 9 of the Federal Law of July 27, 2006 No. 152-FZ "On Personal Data", expresses its will and in its interestconsent to processing(hereinafter referred to as Institution) of the following of their personal data : surname, name, patronymic, year, month, date of birth, sex, place of residence, including information on registration at the place of residence and place of stay, home, cellulartelephones, social category of the family.

The processing of my personal data is carried out by the Institution solely for the purpose of providing me with medical services and forming documents for me as a client of the Institution.

I grant the Institution the right to carry out the following actions with my personal data: collection, systematization, accumulation, storage, clarification, renewal, modification, use, depersonalization, blocking, destruction of personal data to the extent determined by relevant laws and other legal regulations,with the use of paper and electronic media, with the observance of measures to ensure their protection against unauthorized access.

The institution has the right to perform mixed( automated and non-automated) processing of my personal data by entering into an electronic database, including in the reporting forms provided by the documents regulating the provision of reporting data( documents).

I guarantee the confidentiality of my personal data when processing and storing it, which is carried out no longer than the period provided for by the relevant regulatory legal acts.

This consent is permanent, but I reserve the right to withdraw my consent by drawing up a corresponding written document.

"___" _______ 20___ ____________ ____________________

( date)( signature)( decryption of the signature)

For downloading this document, please click here: Consent to the processing of personal data 2017

Journal of citizens' appeal to the clinical psychologist

Appendix 3 to the order of the chief doctorHBUZ "Name of the CRH"

The form of keeping the journal of citizens' appeal to the medical psychologist "The name of the CRH" consists of a table of twelve columns in their headings displayed:

1. Customer code
2. Name
3. Gender;m / f
4. Date of birth / age
5. Date of birth / age
6. Address, telephone
7. Social status / place of work
8. Family status
9. Applicant's code
10. Reason code
11. Problem code / type of request
12. ICD-10 code
13. Recurrence date

Journal of citizens' appeal to a psychologistYou can download here: The Journal of Citizens' Appeal to the Clinical Psychologist 2017

Coding of the personal data of the customer

Appendix 4 to the order of the Chief Medical Officer of the State TB Service "Name of the CRH"

Coding of the client's personal data in theyours elf medical and clinical psychologist is necessary. Since in some cases, and even in the majority, at the request of the client it is necessary to observe complete anonymity of the survey. To do this, you can provide a unique encoding. This model is also very useful for compiling a statistical report.

The code of the client who applied for psychological assistance

The code is meant, that is, the serial number under which the client applied to the medical psychologist has been included once in the "Journal of Appeals of Citizens to the Clinical Psychologist" for the current reporting year. Thus.any citizen who has applied for psychological help has in this journal in one order line only one entry about himself throughout the year, despite any number of visits to a medical psychologist during the current year.

Social status code of the client

1. Preschooler.
2. A student of secondary education institutions.
3. .
4. Student.
5. Working.
6. Disabled.
7. Pensioner for disability.
8. Retired by age.
9. The child is disabled.
10. An orphan child.
11. A child without parental care.
12. The child is neglected.
13. A graduate of an orphanage.
14. Disabled.
15. Unemployed.
16. Forced migrant.
17. Homeless.
18. released from prison.
19. Veteran of the Second World War.
20. A veteran of the fighting.

Family status code of the customer

1. Complete.
2. Incomplete.
3. Childless.
4. Many children are full.
5. Large-scale incomplete.
6. Lonely( after 21 g.).
7. The guardian.
8. Reception.
9. With disabled children.
10. With parents with disabilities.
11. Single mother.
12. Single father.
13. Minor parents.

10
1003
1002
1003	Current life changes( pregnancy, new job, change of residence)
1004	Integration( positive dimensions that cause stress: marriage, new acquaintances)
1005	Other crisis experiences
11	Suicide
1101	Suicidal ideas, thoughts, experiences
1102	Suicidal plan, preparation for suicide( testament, distributionthings, farewell)
1103	Suicidal actions
1104	Previous attempts
1105	Suicide close
1106	Post suicide
1107	Other suicidal treatment
12	Family and conjugal relationship
1201	Family conflict
1202	Conflicts between children
1203	Conflict of spouses
1204	Divorce. The upcoming divorce.
1205	Family betrayal
1206	Family crisis( change in family life: birth of a child, separation related to departure)
1207	Other family and marital problems
13	Relationship of children and parents
1301	Conflict with parents
1302	Conflict with child
1303	Divorce or divorce threat
1304	Parental problems,child development
1305	Adult children, relationships with older children."Empty nest".
1306	Native children. The non-native parents
1307	Abandoned children. Isolation of the child( orphanage, orphanage, boarding school, prison)
1308	Death of one or both parents. Orphanhood
1309	Other problems of child-parent relations
14	Problems of accepting yourself. Existential experiences
1401	External( physical) unattractiveness
1402	Inconsistency with the expectations of the environment( family, friends, colleagues, etc.)
1403	Personal growth difficulties, growing up
1404	Non-acceptance( rejection) of oneself as a person
1405	Loneliness.
1406	Finding, missing or losing the meaning of life
1407	Religious, spiritual issues, questions of faith.
1408	Other existential experiences
1409	Other problems of accepting oneself
15	Communication and relationships
1501	Establishing friendly relations
1502	Difficulties in relationships, misunderstandings, confusion
1503	Difficulties in adapting to a new team
1504	Conflicts( other than production), quarrels
1505	Pressure from reference group or friend
1506	Other communication problems
16	Loving relationships
1601	Difficulties in getting to know
1602	Difficulties in choosing a partner
1603	Difficulties in convergence. Difficulties in the manifestation of love feelings.
1604	Unshared Love
1605	Jealousy
1606	Treason
1607	Cooling the senses, breaking the relationship. Difficulties of parting
1608	Other problems of love relationships
17	Sexual relations
1701	Sexual identity
1702	First sexual experience
1703	Masturbation
1704	Sexual disharmony( impotence, frigidity,. ..)
1705	Homosexuality
1706	Sexual behavior( peeping, demonstration, fetishism, etc.)
1707	Contraception
1708	Junkpregnancy
1709	Incest
1710	Using a consultant as a sexual object
1711	Other problems of sexual relations
18
1801	Addictive Behavior
1802	Nicotine Dependence
1803	Drug Dependence
1804	Alcohol Dependence
1805	Internet Addiction
1806	Game dependence( including computer games), excitability.
1807	Co-dependency
1808	Other problems related to
19	dependencies Health
1901	Experiencing the current traumatic event / process
1902	Mental health and its disorders, depression, "nervous breakdown".
1903	Somatic health and its disorders, complications.
1904	ViDeases
1905	HIV infection, AIDS.
1906	Oncological diseases
1907	Disability
1908	Posttraumatic syndrome( including "Afghan", "Chechen", "Karabakh", etc. syndrome).
1909	Pregnancy
1910	Abortion
1911	Other health related claims
20	Violence
2001	Emotional pressure( threats, blackmail, humiliation)
2002	Domestic violence, unacceptable family life style
2003	Psychological violence against the person( including the action of sects, other informal associations)
2004	Physicalviolence, domestic abuse
2005	Economic violence
2006	Sexual harassment, molestation
2007	Manipulative declination to intimacy( "if you love me, then. ..")
2008	RapeContents;depraved actions.
2009	. Thoughts of murder. Murder plan, preparation.
2010	Post-murder
2011	Other problems related to violence
21	Social adaptation and disadaptation
2101	Violation of social norms( vagrancy, theft)
2102	Violation of the law( including court verdict, summons to the prosecutor's office, police department, FSB, etc.).)
2103	Forced isolation( prison, boarding school, other special institutions) and adaptation after it
2104	Appeal and military service
2105	Social tension
2106	National and international problems
2107	Migration
2108	Material difficulties, poor housing conditions
2109	Other problems of social adaptation
22	Educational and professional problems
2201	Difficulties in choosing a profession
2202	Professional development difficulties
2203	Job placement, job loss, unemployment
2204	Dissatisfaction with study, work
2205	Conflict with teacher
2206	Work conflict
2207	Unwillingness to learn, to work
2208	Other educational and professional problems
23	Others
2301	treatment for another person
2302	Information request
2303	Information about THA
2304	Information about psychological help services
2305	"Just talk"( address due to lack of communication)
2306	Thanks
2307	"Hanging" client
2308	Pathological client
2309	Silence and "control"
2310	Drawing
2311	Wrath and threats to the addressconsultant
2312	Unclassified treatment

life

	code
problem Z 04. Examination and surveillance for other purposes
Z 04.8	Survey and observation for other specified reasons( request for expert opinion)
Z 04.9	Examination and observation for unspecified reasons
Z 09. Follow-up examination after treatment of conditions other than malignancy
Z 09.3	Follow-up examination after psychotherapy
Z 50. Assistance, including the use of rehabilitation procedures
Z 50.2	Rehabilitation of persons with alcoholism
Z 50.3	Rehabilitation of drug addicts
Z 50.4	Psychotherapy not elsewhere classified
Z 50.8	Treatment including other types of rehabilitation procedures( smoking rehabilitation, self-service training for the NCDR)
Z54. Recovery state
Z 54.3	Recovery state after psychotherapy
Z 55. Learning and literacy problems( excluding psychological development disorders - F 80 - F 89
Z 55.0	Illiteracy
Z 55.1	Lack of learning ability
Z 55.2	Failure in examinations
Z 55.3	Learning lag
Z 55.4	Poor adaptation to the teaching process, conflicts with teachers and fellow students
Z 55.8	Inadequate training
Z 56. Job and unemployment problems
Z 56.0	No work
Z 56.1	Work change
Z 56.2	Threat of loss of work
Z 56.3	Strained working schedule
Z 56.4	Conflict with the supervisor and
Z 56.5	Inappropriate work
Z 56.6	Other psychophysical stress in work
Z 57. Exposure to production risk factors
Z 57.8	Adverse effects of other risk factors
Z 58. Problems related to physical environmental factors
Z 58.8	Othersproblems related to physical environmental factors
Z 59. Problems related to housing and economic circumstances
Z 59.0	Homelessness
Z 59.1	Unsatisfactorynye housing
Z 59.2	conflicts with neighbors, lodgers, masters
Z 59.5	Extreme poverty
Z 59.6	Low income
Z 59.8	Other problems
Z 60. The problems associated with adaptation to changes in the image
Z 60.0	Retirement, loneliness syndrome
Z 60.1	Problems with parenting or with stepfather
Z 60.2	Living alone
Z 60.3	Difficulties in accepting another culture( migration, changesin social status)
Z 60.8	Other problems related to the social environment
Z 61. Problems associated with adverse life events in childhood( excluding ill-treatment syndrome - T 74: T 74.1 - physical cruelty, T 74.2 - cruelty is sexualI, T 74.3 - Psychological cruelty
Z 61.0	Loss of loved ones in childhood( death, absence, suspension)
Z 61.1	Excommunication from home( shelter, hospital, army)
Z 61.2	Parents' new marriage, the birth of another child
Z 61.3	Decreased self-esteem in childhood( failure, shameful episodes)
Z 61.4	Problems associated with possible sexual assault of a child by a person belonging to the primary support group
Z 61.5	Rape by an unauthorized person
Z 61.6	Problems,
Z 61.7	Personal traumas borne in childhood( kidnapping, element, injury, injuries inflicted on a child's life in his presence)
Z 61.8	Other adverse life events( related to possible physical abuse of the child)in childhood
Z 62. Other problems related to raising a child( excl. T 74)
Z 62.0	Poor child control
Z 62.1	Hyperopeka
Z 62.2	Education in a closed institution
Z 62.3	Hostility towards unfair claims to the child
Z 62.4	Emotional abandonment of children( no heat, indifference)
Z 62.5	Other problems related to upbringing( lack of it) - lack of training and play experience in the child
Z 62.6	Unacceptable pressure from parents and others( requiring excessive responsibilityboyfriend, girl, do what is beyond the limits of the rules)
Z 62.8	Other specified problems related to the upbringing of the child
Z 63. Other problems related to close people
Z 63.0	Disagreements between spouses
Z 63.1	Disagreements between parentsor relatives of the wife, husband
Z 63.2	Insufficient family support
Z 63.3	Absence of family member
Z 63.4	Disappearance and death of a family member
Z 63.5	Family breakdown
Z 63.6	Dependent family member who needs care
Z 63.7	Other stressful life events affecting the family and economic conditions: - anxiety( normal) about the affected family member; - health problems in the family; - illness; violation of the family member; - an isolated family.
Z 63.8	Other specified problems related to the primary support group( disagreements, emotional level increased, frustrated relationships).
Z 64. Problems associated with certain psychosocial circumstances
Z 64.3	Finding and accepting behavioral and psychological actions known as harmful and dangerous
Z 65. Problems related to other psychosocial circumstances
Z 65.8	Other specified issues related towith psychological circumstances
Z 70. Consultations concerning sexual relations, behavior and orientation
Z 70.0	Counseling concerning the attitude to the sexual issue(a person experiencing embarrassment, shyness, or other difficulty in connection with sexual matters)
Z 70.1	Counseling related to sexual behavior or sexual orientation( patient concerned: impotence, lack of reaction, promiscuity, sexual orientation)
Z 70.2	Counseling,(advice on sexual behavior or orientation: child, partner, spouse)
Z 70.3	Counseling concerning complex problems withsexual behavior, behavior and orientation
Z 70.8	Other advice regarding sex( sex education)
Z 70.9	Sexual counseling, unspecified
Z 71. Contacting health authorities for other advice and medical advice not classified elsewhereheadings
Z 71.0	Seeking for advice on behalf of another person( excl. Z63.7)
Z 71.1	Complaints caused by fear of the disease in its absence
Z 71.2	appeal for clarification of the results of research
Z 71.3	Consultation on Nutrition
Z 71.4	consultation and supervision for alcoholism( excluding Z50.2)
Z 71.5	Consultation and supervision of drug addiction( excluding Z50.3)
Z 71.6	Consultation and supervision of smoking( excluding Z50.8)
Z 72. Lifestyle problems
Z 72.3	Lack of physical activity
Z72.6	SkGambling and betting( excluding compulsive or pathological attraction to gambling( F63.0))
Z 72.8	Other lifestyle problems( behavior leading to self-harm)
Z 73. Problems related to the difficulty of maintainingof a normal life
Z 73.0	Overstrain
Z 73.1	Accentuated personality traits
Z 73.2	Inadequacy of rest and relaxation
Z 73.3	Stress state not classified elsewhere( physical and mental stress)
Z 73.5	Conflict associated with the social role, not elsewhere classified
Z 73.6	Activity restriction caused by a decrease or loss of ability to work
Z 91. In a personal history, the presence of risk factors not elsewhere classified
Z 91.4	In a personal history, a psychological trauma not classified elsewhere
Z 91.5	In a personal anamnesis, self-harm( parasuiticide, self-poisoning, suicide attempt)
R 40- 46. Symptoms and signs related to cognitive ability, perception, emotional state and behavior
R 40. Somnolence, stupor, coma( except coma: diabetic, hepatic, hypoglycemic, uremic, neonatal
R 40.0	Somnolence( hypersomnia), drowsiness
R 40.1	Stupor( precoma)( excluding cataractic stupor( F20.2), depressive( F31-33), dissociative( F 44.2), manic( F 30.2)
R 40.2	Unconscious state of BDU( coma, unspecified)
R 41. Other symptoms and signs related to cognition and awareness( excl. Disparity disorders( F 44))
R 41.0	Guidance disorders, unspecified( obscuration of the consciousness of the BSU( except for psychogenic impairment of the orientation( F 44.8)
R 41.1	Anterograde amnesia
R 41.2	Retrograde amnesia
R 41.3	Amnesia of the BDU
R 41.8	Other unspecified symptoms related to cognition and awareness
R 43. Disturbances of smell and taste sensitivity
R 43.0	Anosmia
R 43.1	Parosmia
R 43.2	Paraguay
R 43.8	Other and unspecified disorders of smell and taste sensitivity( combined malignancy and taste)
R 44. Other symptoms and signs related to general sensations and perceptions( excluding skin sensitivity disorders( R20.-)
R 44.0	Hallucinationsauditory
R 44.1	Hallucinations visual
R 44.2	Other hallucinations
R 44.3	Hallucinations, unspecified
R 44.8	Other unspecified symptoms related to general sensations and perception
R 45. Symptoms and prizeemotional state
R 45.0	Nervousness
R 45.1	Anxiety and arousal
R 45.2	State of anxiety due to failures and unhappiness( anxiety state of the BDU)
R 45.3	Demoralization and apathy
R 45.4	Irritability and bitterness
R 45.5	Hostility
R 45.6	Physical aggressiveness
R 45.7	Condition of emotional shock and stress, unspecified
R 45.8	Other symptoms related to emotionalstate
R 46. Symptoms and signs related to appearance and behavior
R 46.0	Very low level of personal hygiene
R 46.1	Bizarre appearance
R 46.2	Strange and unexplained behavior
R 46.3	Excessive activity
R 46.4	Retardation, delayed reaction( excluding stupor - R 40.1)
R 46.5	Suspicion and overt hesitation
R 46.6	Excessive interest and increased attention to stressful events
R 46.7	Verbosity and unnecessary details making the cause of contact unclear
R 46.8	Other symptoms and signs related to externalin appearance and behavior.

Note: the entry may not be limited to using only one code from the corresponding group. If there is a need for clarifications and additions, some other suitable code from the group can be put forward, for example, 02 - single parent family, 11 - single mother, 13 - minor - 02 /11/ 13.

Code of the person who applied for psychological assistance

No.	Code	Subject of treatment
12345678910	MJ. .. R. .. O. .. P. .. C. .. A. .. B. .. Z. ..	Boy( boy), male Girl( woman) WomanRoman Guardian( person replacing parents) Teaching workerSocial worker( representative of the protection of children's rights,defendings) A representative of the administration of the educational bodies of internal uchrezhdeniyaSotrudnik delRabotnik health facilities

Codes handling reasons

Option 1

№	code Reason for Reason for
12345678	About. .. In. .. P. .. E. .. I. .. F. .. OM. .. Prof.	Learning-related problemsProblems related to behaviorEmotional problemsDefinition of the level of current developmentProblems related to speech developmentDetermination of the further educational routeProfessional orientation

The ellipsis after the code means that this code can be detailed( with the help of letters or digits).For example, the code "P"( parent), if necessary, can be specified: "Рм" or "Рд"( similarly, and other codes of the applicants), and the "O" code of such a treatment reason, as learning problems, can be detailed as "О1"- problems of mastery of the primary school program, "O1-M" - problems of mastering mathematics in the elementary school, etc.

Option 2

Reason code	Reason for contact
01	Family and matrimonial relations
02	Parent-child relationship
03	Love relationship
04	Interpersonal relationship
05	Intrapersonal problems
06	Social adaptation and disadaptation
07	Violence
08	Career orientation
09	Dependencies and codependencies
10	Problems related to study / work
11	Crisis
12	Other

Codification of problematic calls

Coding of problems for ICD-10

Codes of problems for medical clan"Factors Affecting Health", "Symptoms, Signs and Deviations from the Standard":

Coding of the client's personal data in the activity of a clinical or medical psychologist. The "CRHD" Name of the CRH was developed on the basis of the Methodological recommendations for the implementation of the requirements of the state social standardservice of the population of the Volgograd region "Provision of social and psychological services to citizens in a difficult life situation".Volgograd, 2010, Medical classification of diseases of the tenth revision, 1995.

This attachment to the order can be downloaded here: Coding of the client's personal data of a medical psychologist.

Individual psychological card of the psychologist's client

Appendix 5 to the order of the Chief Medical Officer of the State Health Care Institution "The Name of the Central District Hospital"

The individual psychological card of the client of the medical psychologist of the State Medical Clinical Hospital "CRH Name" has such approximate parameters. I quote one of the completed psychological maps as an example.

1. Customer code 37,
2. Sex: m / f, F,
3. Date of birth / age 33 y.,
4. Place of residence Art. Name,
5. Soc.status 06,
6. Family status 01,
7. Caller ID,
8. Reason code of reference 12,
9. Problem code / type of treatment 1903,
10. ICD-10 code Z04.8.

Wednesday, 17 February 2017 Counseling.

The client undergoes inpatient treatment in the GPHU therapeutic unit "CRH Name" due to the worsening of the physical condition. The initiative of applying for a consultation with a medical psychologist comes from her treating doctor, and not from the client herself. According to the attending physician, the client has anorexia, sleep disorders, depressive state and exhaustion of nervous processes.

The appearance of the client is untidy, the face is somewhat edematous, low nutrition, speech is quiet, during counseling was mostly lying in bed. On the question of whether she is going out into the street or into the corridor for a walk with the goal of creating a useful daily exercise to improve the quality of a night's sleep - answers in the affirmative.

Contact is available, geared in place, time, self. Without difficulty, he calls his home address correctly, the date of his birth. The client is recommended a psychodiagnostic examination.

02/17/2017 Psychodiagnostic examination

No resistance was encountered in relation to the psychodiagnostic examination by the client. Tasks performed willingly, although the attitude to the survey is indifferent.

Sensomotor sphere, attention, cognitive sphere.

Methodology: Schulte tables .Lead time.

Table №1 - 93 seconds, №2 - 90 seconds, №3 - 80 seconds, №4 - 91 seconds, №5 - 95 seconds.

Methodology - test CFIT - R. Cattella.

Only a few initial tasks are performed due to the client's fatigue. From the 1st subtest - 12 tasks - 8 errors. The client can not fully understand the meaning of the solution of the simple tasks presented.

Methodology: Simple analogies.

Of the first 10 tasks - 5 it was decided wrong.

Conclusion: attention is very unstable, performance in the dynamics is very low, fatigue / exhaustion of nervous processes is expressed, the thinking process is unstable and fragile. The process of operating with simple analogies is broken.

At the moment, it is impossible to say unambiguously about the level of intellectual development and the type of thinking in connection with the rather deep disorders of the somatic state.

Emotional-volitional sphere and personal sphere. Method: Color Selection Method( MCW) *.

Methodology: Portion election method( MPV) *.

* Note: the data from the tables you will find in the file of the "dock" format, indicated below.

ICD data: color selection method

Self-regulation is weakened. The sympathetic tone prevails( the process of excitation).Emotional tension is minimal with a tendency to decrease. Emotional lability. Weak control over the emotional sphere. Reaction to emotional stress in the direction of disorganization. Positive emotional background. Extraversion( the direction of the personality outside).Working capacity is reduced. The minimal degree of conflict between anabolic and catabolic tendencies( the desire to accumulate and expend energy).The coefficient of vegetative balance = 14/7.

Functional pairs:

-1-6.Stress, expressed dissatisfaction, which is caused by a sense of humiliation and is manifested by restrictive behavior. Dependence of position, uncertainty.increased sensitivity to environmental influences. The expressed control is considered as the unique guarantee of self-affirmation and defending of the positions. The main problems are lack of recognition and increased self-control.

+ 3-1.Dissatisfaction with the experience of loss or discord in the sphere of deep affection. The desire to forget yourself in hard work.

IPV data: portrait election method

We list the most active factors.

hy- - Mixed unstable type of higher nervous activity. Emotionally immature, unstable, emotive type of response. Instability and variability of emotions, demonstrativeness, contradictory attitudes, capriciousness, dramatization of existing problems. High probability of development of psychosomatic disorders. With the deformation of drives, a high probability of developing deviant behavior.

The need for further psychological research to clarify the personal profile.

The client is recommended to lead a healthy lifestyle, revise life priorities, study the information and methodological booklet "Autogenic training".

Clinical psychologist IO Surname 17.02.2017

This appendix to the order is the development of the author of the Rainbow website / How to solve the problem / http: //alcostad.ru/: sample document in docx format you can download here: Individual psychological client card.

Unfilled form here: Form of an individual psychological card of a client of a medical psychologist.

Journal of the Consultative Work of the Psychologist

Appendix 6 to the order of the Chief Medical Officer of the State TB Service "Name of the CRH"

An example of the journal of the consultative work of a psychologist can be downloaded here: Journal of the Consultative Work of a Clinical Psychologist.

It consists of six columns, in which it is registered:

1. No.
2. Date and time
3. Treatment( primary / repeated)
4. Consultant: client( code), age, gender.
5. Reason for request or Problem
6. Result

Note:

1. Only one service is recorded in the journal - psychological counseling.
2. "Circulation" specifies the type of treatment: primary or secondary.
3. The column "Reason for circulation" prescribes the following options:

• on what or to whom the consultant complains;
• what kind of help awaits( "advise", "teach", "influence", etc.).

* can be encoded on the basis of the reasons for the request and the type of the client's request, according to the encoding of the client's personal data in the activity of the clinical psychologist of the HBIS "CRH Name"( Appendix 3 to the order of the Chief Physician).

1. The graph "Problem" prescribes the following options:

• initial state of the client( the consultant was in a position: anxiety, doubt, uncertainty, despondency, shock, uncertainty, in a vicious circle of conflict, in search of participation, psychological intoxication, aesthetic personalizationproblems, manipulation, etc. - it is necessary to indicate in which area);

* can be coded based on the type of treatment and / or ICD-10, according to the encoding of the client's personal data in the activity of the medical psychologist of the State Health Insurance Institution "Name of the CRH"( Appendix 3 to the order of the head physician).

• are the difficulties of the client( "I want. .., but I can not. ..");
• self-diagnosis( as the client explains the reasons for his difficulties).

1. In column "Result" the following options are prescribed:

• what is the nature of the problem( the problem is classified as acute, requiring immediate help, carries a suicide risk, requiring the help of other specialists - a psychiatrist, a psychotherapist, speech therapist, social worker, etc., is not acute, etc.);
• what was done( general emotional support provided, support for the decision taken, joint analysis and discussion of the life situation and life alternative, information on institutions providing. .. information on marital and family relationships, information on age characteristics. .., recommendationsin the field of professional problems / family relations / relations with children / personal problems, rapid diagnostics. .. etc.);
• general recommendations( the problem requires additional meetings - specify the date and time of the next consultation, the participation of the client in the program "..." is necessary, the client must be transferred to another counselor psychologist, etc.);
• level of customer satisfaction( the client is completely satisfied / not satisfied / difficult to determine the level of satisfaction / is not satisfied with the consultation, etc.).

Journal of psychodiagnostic work of the psychologist

Appendix 7 to the order of the chief doctor of the state health care institution "Name of the CRH"

The journal of the psychodiagnostic work of the clinical psychologist of the HBIS "CRB name" consists of six columns, in which:

1. No.
2. Date and time
3. Appeal(primary / secondary)
4. Consultant: client( code), age, gender.
5. Reason for handling or Problem
6. Result

It is very similar to the previous log.

Note:

1. Only one service is recorded in the journal - psychological diagnosis.
2. "Circulation" specifies the type of treatment: primary or secondary.
3. The column "Reason for circulation" prescribes the following options:

• on what or to whom complains diagnosed;
• what kind of help is waiting( "advise", "teach", "influence", etc.).

* can be coded based on the reasons for the treatment and the type of the client's request, according to the encoding of the client's personal data in the activity of the medical psychologist of the HBIS "Name of the CRH"( Appendix 3 to the order of the head physician).

1. The
   1. column "Problem" prescribes the following options:
   • the initial state of the client( the consultant was in a position: anxiety, doubt, uncertainty, despondency, shock, uncertainty, in a vicious circle of conflict, in seeking participation, psychological intoxication, aesthetic personalizationproblems, manipulation, etc. - it is necessary to indicate in which area);

   * can be coded based on the type of treatment and / or ICD-10, according to the encoding of the client's personal data in the activity of the medical psychologist of the HBIS "CRH Name"( Appendix 3 to the order of the Chief Physician).

   • are the difficulties of the client( "I want. .., but I can not. ..");
   • self-diagnosis( as the client explains the reasons for his difficulties).
   1. In column "Result" the following options are prescribed:
   • what is the nature of the problem( the problem is classified as acute, requiring immediate help, carries a suicide risk, requiring the help of other specialists - a psychiatrist, a psychotherapist, speech therapist, social worker, etc., is not acute, etc.);
   • what was done( general emotional support provided, support for the decision taken, joint analysis and discussion of the life situation and life alternative, information on institutions providing. .. information on marital and family relationships, information on age characteristics. .., recommendationsin the field of professional problems / family relations / relations with children / personal problems, rapid diagnostics. .. etc.);
   • general recommendations( the problem requires additional meetings - specify the date and time of the next consultation, the participation of the client in the program "..." is necessary, the client must be transferred to another counselor psychologist, etc.);
   • level of customer satisfaction( the client is completely satisfied / not satisfied / difficult to determine the level of satisfaction / not satisfied with the diagnosis, etc.).

   The journal of psychodiagnostic work of a psychologist in text format can be downloaded here: Journal of psychodiagnostic work of a clinical psychologist.

   Diary of the individual psycho-correctional work of the psychologist

   Appendix 8 to the order of the chief doctor of the State Health Care Institution "The name of the CRH"

   The diary of the individual psycho-corrective work of the medical / clinical psychologist GBUZ "CRB Name" consists of six columns with the following content:

   1. No.
   2. Date and time.
   3. Treatment( primary / repeated).
   4. Customer data: code, age, sex.
   5. Techniques and techniques for psycho-correction interventions.
   6. Dynamics in the state and behavior of the client.

   Note:

   1. Only one service is recorded in the journal - psychological correction.
   2. "Circulation" specifies the type of treatment: primary or secondary.
   3. In the column "Techniques and receptions of psycho-correction interventions" , psychological methods used in psycho-correction exercises are prescribed accordingly.
   4. In the column "Dynamics in the state and behavior of the client" the results of the psycho-corrective measures, recommendations are prescribed.

   This appendix to the order can be downloaded here: Diary of an individual psycho-correctional work of a medical psychologist.

   Diary of the group psycho-correctional work of the psychologist

   Appendix 9 to the order of the chief doctor of the State Medical Academy of the Republic of Uzbekistan "Name of the CRH"

   The diary of the group psycho-corrective work of the medical /medical psychologist.

   Report on the activity of the psychologist

   Appendix 10 to the order of the chief doctor of the medical center "Name of the CRH"

   Report on the results of the activity of the medical / clinical psychologist GBSU "Name of the Central Bank"

   for ___________________ 201_ years

   Number of psychopathogical conclusions

   Number of psychological consultations

   Individual psychosocorrection-taking

   Group psychosocorjunctional seizuresNumber of working hours: _____________. Number of psychodiagnostic conclusions by forms: Form 0 ________, Form 1________, Form 2________, Form 3_________. Total in Form 1: ___________. Medical / clinical psychologist _____________ _______________________ ( signature)( surname, initials) "___" _____________ 201__ This annex to the order - the form - can be found here: Report on the activities of the clinical and medical psychologist Requirement for examination and psychodiagnostic conclusions Appendix 11 to the order of the chief doctor of the State Health Care Institution "Name of the CRH" The requirements for the experimental psychological examination and psychodiagnostic conclusions in the activity of the medical / clinical psychologist of the GBUZ "CRH Name" and the standards of psychocorrection work can be found here: Forms of psychodiagnosticconclusions. There are 4 forms of psychodiagnostic conclusions: Form 0: Conclusion according to neuropsychological examination, as a survey of increased complexity, requiring high qualification of a medical psychologist. Conclusion for a comprehensive forensic psycho-psychiatric examination, which is a complete psychodiagnostic examination and the answers of an expert psychologist to the questions posed. Form 1: Conclusion according to the data of complete psychodiagnostic examination. As a rule, it is conducted in connection with the tasks of differential diagnosis, clarification of the degree and depth of disorders of mental activity, the identification of the preserved and broken links in the psyche, while solving expert questions. Form 2: Conclusion according to the partial examination - sensorimotor, cognitive, or emotional-volitional and personal spheres. As a rule, it is conducted in the clinic of neuroses and in patients of the general-somatic profile( clarification of personal characteristics, features of the emotional-volitional sphere). Form 3: Conclusion from the survey using the MMPI questionnaire with a detailed analysis of the personality profile of the subject. It is shown to identify the personality characteristics of the subject, to evaluate the effectiveness of ongoing psychotherapy, both individual and group. A set of necessary methods is proposed, which should be used in the survey( basic methods) and a set of additional techniques that can be varied at the discretion of a specialist psychologist. For the convenience of counting, the total number of reports for the reporting period is reduced to the number of conclusions on form 1. Taking into account the time required for conducting the survey, analyzing the results and writing the conclusion, the normative workloads of the medical psychologist can be 16 conclusions on Form 1 per month forone rate of a medical psychologist( with a 36-hour work week) - in a hospital. In the outpatient service - , 20 conclusions on form 1 per month. At the end of the month the psychologist presents a report on his work( Appendix 9 ). The following are the requirements for experimental psychological examination and conclusions. Survey requirements and conclusions To conclusion on form 1 ( total labor for 1 conclusion 9-10 hours): Investigation of sensorimotor sphere and attention Basic techniques: Additional methods: Schulte tables and their modifications Krepelin scoreCorrective testMethodics of CoaxNeuropsychological testsCountingMagazine Investigating the cognitive sphere ( memory, thinking, intelligence, associative processes) Learning 10 wordsEntertainment of memory(by Leontiev or pictogram) Verbal associationsScientific signs4th extra( exclusion of subjects) Comparison of concepts For(subject pictures) Classification of objects Interpretation of proverbs and metaphorsAlongation of sequence of events Simple and complex analogies Explaining the meaning and content of plot pictures Counting the Method of Coos Test of Ravena Test of Veksler( subtests) Ebbinghausa test Neural pictures Neuropsychological subtests Investigating the emotional-volitional sphere and the personal sphere Self-esteem study + conversationLusher's test The variant of the projectivedrawing( drawing of a person,om-tree-human, non-existent animal, etc.) MMRI Test RosenzweigM uncompleted sentencesM-diagnostics of value orientationsM- assessment of the level of claimsTematic associationsTest Cattell Test SondiTest "Hand" TATTEST RorschachMary LiriUTSvettovat test of relations To conclusion on form 2 ( total labor for 1 conclusion of 5-6 hours): Study of one or two of these areas. All basic techniques for examining a specific mental sphere plus 2-3 of additional( at the discretion of the psychologist). Two conclusions on form 2 are equated to one conclusion on form 1. To conclusion on form 3 ( total labor 3-4 hours): The questionnaire of MMPI with the interpretation of the personal profile. Three conclusions on form 3 are equated to one conclusion on form 1. To conclusion on form 0 ( total labor 20-25 hours): One conclusion on form 0 equates to three conclusions on form 1 - in hospital, to two conclusionsForm 1 - in the outpatient service. Note: In the study of patients: with decreased intelligence;defects of hearing, sight;with a general poor physical condition, a reduction in the number of methods is possible. Similarly - when examining patients in an ambulatory service with a time deficit. The list of additional techniques can not be given in full because of their large number. Psychological study of children includes techniques specific for this contingent of subjects. Standards for the psycho-correctional work of a medical psychologist: A. Group psycho-correctional work Any group work requires careful theoretical and methodological preparation, analysis of previous studies and the behavior of each participant, assessing the dynamics in the state of each member of the group. Taking into account these conditions, it is recommended that two group sessions per day be held at the rate of a medical psychologist, which includes the following stages: Preparation of the room, methodical manuals, task formulation, group session scenario writing - 30 minutes. Introduction and "warm-up"( warm-up) - the initial stage of the group's work - 15-20 minutes. Implementation of the main tasks - the main stage of the group's work - 60 minutes. Summing up the group session - the final stage - 15 minutes. Documentary registration of a group psychocorrectional / psychotherapeutic session( filling out a formalized form of group work or describing a group lesson in the diary of group psychocorrection work - Appendix 8) - 45 minutes. B. Individual psycho-correctional work A psychologist can conduct no more than four individual psychocorrectional sessions per one work day, that is, one session takes 90 minutes, which includes: Preparation for the lesson( reading of special literature, talking with the attending physician, studying the medical history, and in case of repeated studies -analysis of previous meetings) - 15 minutes. Lesson - 60 minutes. A record of the occupation in the medical history, the journal of the account and( or) in a special diary of individual psycho-corrective work( Appendix 7 ) - 15 minutes. This appendix to the order on paper can be found here: Form for the conclusion of the consultation of the medical and clinical psychologist Procedure for registering a referral for an experimental psychological examination to a psychologist Appendix 12 to the order of the chief doctor of the State TB Service "Name of the CRH" Procedure for registering an experimental psychologicalan examination to a medical / clinical psychologist at the HMPS "CRH Name" can be found here: The order of referral to a psychodiagnostic examination in the direction indicated by the following patient data: patient's name. Year of birth. Initial diagnosis( or diagnostic versions). The task of the study. Variants of A. Differential diagnosis( with the detection of the pathopsychological symptom complex inherent in this or that mental illness); B. Refinement of the degree of severity( depth) of the disorders present in the subject( reduction of intelligence, depth of emotional-volitional disorders, personality changes, etc.);B. Detection of the structure of disturbed and preserved links in mental activity; D. Identification of the setting trends( simulation, dissimulation, aggravation, simsimulation, metasimulation); D. Evaluation of the dynamics of neuropsychic disorders; E. Diagnosis of the level of mental development for the choice of training and retraining. Purpose of the study Variants: VVC;MSEC;SSPE;CASA;KEK;school examination;evaluation of the effectiveness of therapy;choice of ways of therapy and correction. Attending physician ____________ _____________________ signature surname, initials «___» ____________ 201__ Related Videos Clinical and Medical Psychology Well, like everything, success to you in the practical work of a psychologist! I hope, my information will bring you great benefits and facilitate the work. Sincerely, the author of the site: http: //alcostad.ru/