How to fill in the psychological consultation record

There are not so many rigid rules when filling out psychological consultation records. If you stick to the three basic principles of "prioritizing facts, keeping ethical boundaries, and considering the well-being of the client", you will not make big mistakes. The remaining details can be adjusted according to the school requirements and institutional norms.

Speaking of which, I encountered some pitfalls when I first entered the industry. The first time I took on a case, I clearly wrote down the details of the visitor’s complaints about his roommate’s stealing of luxury cosmetics, and also mentioned that the visitor was a junior broadcaster at a communication university. When the supervisor saw the first sentence, he asked me: “Are you afraid that others won’t be able to find out who this visitor is? ”Only later did I figure out that unless it is information that must be filed under judicial requirements, all content that may identify the visitor must be blurred. The real name can be replaced by a code name, and the specific unit or school does not need to be written in full. The identity information is stored in an encrypted file separately and must not be placed on the same table as the consultation content. This thing is to put it bluntly, it is the visitor's "psychological treatment security code."

The record-filling styles of consultants with different orientations are quite different, and there is no forced uniformity in the industry. I used to work with a senior who was doing CBT on a case study. His records were written every time like a test preparation book. What social training assignments were assigned on which day? Where did the client get stuck when completing them? Which automatic thinking was adjusted? Everything was clear. Next time I consult, I can just adjust the plan directly to the records. It is very efficient. ； But I work in dynamics. The record is usually only half a page. I will only write "This time around early parent-child issues, the client has obvious emotional improvement, and we can continue to follow up." I will not even mention the specific events discussed. After all, much of the work content of dynamics is a secret consensus between the counselor and the client. Writing too detailed may undermine the safety of subsequent interviews. Both approaches are reasonable. As long as it conforms to the operating standards of your school and does not touch ethical red lines, there is no problem.

Of course, there are a few hard levers that cannot be touched by any school or institution. The most important thing is not to be vague about the risk assessment column. Last month, I heard an industry supervisor talk about a case. When a consultant was interviewed, the visitor mentioned, "I've been under a lot of pressure recently and sometimes I stood by the window on the 12th floor and wanted to jump out." The consultant felt that it was just a casual comment without intervention or writing in the record. Later, the visitor actually fell from the building, and the family members retrieved the consultation records and found nothing relevant. The consultant not only lost a lot of money, but also had his professional qualification revoked. It was really not worth the gain. If you really encounter a visitor who is at risk of self-injury, suicide, or harm to others, you must not only clearly write down the risk level, but also write down exactly what intervention you made, whether you notified the emergency contact, and what the visitor's feedback was at the time. This is not an unnecessary step, but is responsible for both you and the visitor.

Oh, by the way, if you are new to the industry and are really not sure whether filling it out like this is appropriate, ask yourself a question first: "If this record is seen by the visitor tomorrow, will it hurt him?" ”If the answer is no, then there's basically no problem.