Structure of the Clinical History

Definition and Legal Characteristics

The clinical history is defined as a medical-legal document where all the patient's information necessary for a correct approach is collected in a systematic, organized, thorough and detailed manner.

Unlike the interview, which is the technique or script to obtain information, the clinical history is the formal document where such data is stored.

This document has fundamental characteristics: it is unique for each patient (it is not made for each family), individualized and personalized.

In addition, it is strictly confidential; no person outside the professional practice (such as school principals or coordinators without psychological competence) should have access to it, since doing so would violate the ethical and legal principles of the profession.

Sociodemographic Identification Data

The first block of the clinical history should contain complete identification data, and not be limited to first and last name only.

It is necessary to record age, identity card, date and place of birth, sex, marital status, education level, occupation, religion and home address.

Contact information (personal, room and work telephone numbers) and who the patient lives with should also be included.

In the case of infant-juvenile patients, it is also mandatory to include the complete data of the mother, father or legal representative, since there may be situations where the parents are not present due to migration or death.

Obvious information should not be assumed; for example, occupation may not coincide with educational level, so specific inquiries should be made.

Summary

The medical history is a systematic and detailed medico-legal document, distinct from the interview. It is strictly confidential, unique and personalized, and its access is forbidden to outsiders.

The identification block must be exhaustive, recording data such as age, identity card number, marital status and religion. Obvious information should not be assumed, and it is necessary to specifically inquire about occupation and level of education.

In infant-juvenile patients, it is mandatory to record the complete data of the parents or legal representatives. This covers legal gaps in situations where parents are absent due to migration or death.