Reason for Consultation and History

Apparent vs. Real Reason

The reason for consultation should be recorded in the clinical history, differentiating between the apparent and the real reason.

The apparent reason is the explicit reason given by the patient upon arrival (e.g. "I have been referred"), while the real reason is what the psychologist determines after evaluating and analyzing the situation (e.g. anger management or anxiety problems).

It is the evaluator's responsibility to delve beyond the initial complaint to discover the true cause of the conflict or discomfort.

Current Illness and History

The "current situation" or "current illness" section should be a detailed compilation of the patient's presenting problems, maintaining a direct relationship to the reason for the consultation.

Irrelevant information that does not connect to the current process should be avoided.

Although "verbatim" (verbatim words of the patient in quotation marks) can be used, care should be taken not to overdo it; the clinical history should also reflect the clinical judgment and perception of the professional, not be a literal transcription of the session.

As for the medical history, both personal and family history should be investigated, covering medical, psychiatric, psychological and legal areas.

If the patient indicates that there are no antecedents, it should be technically recorded as "denies antecedents", which serves as legal support in case the patient changes his version later.

Summary

It is essential to record the reason for consultation, differentiating between the apparent reason, expressed by the patient, and the real reason, determined by the psychologist after analyzing the background situation.

The current illness section details the problems linked to the motive. It should balance the patient's textual words with the clinical judgment of the professional, avoiding being a simple literal transcription.

Personal and family medical, psychiatric and legal history should be sought. If the patient indicates that they do not exist, it is technically recorded as "denies antecedents" for future legal support.