Asignatura:

Psicología Clínica

Título del trabajo:

Historias clínicas y consentimiento informado

Presentan:

Johnatan Mejía Ruiz - ID 608908

Luis Alberto Arbeláez Velásquez - ID 335293

María Alejandra García - ID 608888

Natalia Giraldo Fernández - ID 614947

Docente:

Jacqueline Cobo Rojas

Colombia, Guadalajara de Buga Marzo 27 de 2020

 HISTORIA CLÍNICA (Mayores de 18 años)

1. Ficha de identificación:

- Nombre:

- Sexo:

- Edad:

- Fecha de nacimiento:

- Lugar de nacimiento:

- Dirección:

- Escolaridad:

- Ocupación

- C.C:

- Estado civil:

- Número de hijos:

- Numero de contacto:

- Dirección:

- Barrio:
 2. Motivo de consulta:

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3. Familiograma:
 4. Antecedentes clínicos:

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 5. Hábitos

Sexuales, Tabáquicos, Alcohólicos:

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 6. Datos clínicos familiares:

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 7. Observaciones generales:

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 8. Sintomatología actual:

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 9. Hipótesis:

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 10. Recomendaciones:

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EVALUACIÓN REALIZADA POR: ______________________________________________

 HISTORIA CLINICA PSICOLOGICA (Menores de 18 años)

1. DATOS PERSONALES:

Nombres: ________________________________________________________________

Apellidos: ________________________________________________________________

Fecha de nacimiento: ______________________________________________________

Edad actual: ______________________________________________________________

Domicilio: ________________________________________________________________

Institución / tipo de educación: ______________________________________________

Grado cursando: __________________________________________________________

En caso de emergencia comunicarse con:

Contacto 1: _______________________________________________________________

Contacto 2: _______________________________________________________________

Contacto 3: _______________________________________________________________

Fecha actual: _____________________________________________________________

C.C. O T.I.: ______________________________________________________________

 2. MOTIVO DE LA CONSULTA:

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 3. HISTORIA DE ENFERMEDADES:

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 4. AMNESIS PERSONAL

- EMBARAZO:

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- PARTO:

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- ENFERMEDADES E HISTORIAS DE LAS MISMAS:

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 5. DESARROLLO PSICOMOTRIZ:

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 6. ANTESCEDENTES PATOLOGICOS:

- PADRES:

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- HERMANOS:

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- ABUELOS:

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 - TIOS:

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- PATOLOGIAS SOBRESALIENTES:

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 7. ESCOLARIDAD: HABILIDADES ALCANZADAS:

- GUARDERIA:

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- ESCUELA REGULAR:

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- ESCUELA ESPECIAL:

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 - COLEGIO:

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- ADAPTACIONES CURRICULARAS:

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- CONOCIMOENTOS ALCANZADOS:

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 8. COMPORTAMIENTO:

- AGRESIVO:

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- DESADAPTADO:

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- DISTRAIDO:

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 - INDIFERENTE:

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- DESOBEDIENTE:

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- RESISTENTE:

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 9. REPORTE QUE SE TIENE A NIVEL PSICOAFECTIVO:

- PADRES:

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- DOCENTES:

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- OTROS:

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 10. REPORTE QUE SE TIENE A NIVEL COGNITIVO:

- PADRES

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- DONCENTES:

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- OTROS:

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 COSENTIMIENTO INFORMADO

Fecha: _____________________________ Ciudad: ______________________________

El siguiente documento es de carácter informativo y tiene por tanto la intención de informar

al candidato a evaluar, sobre los compromisos y derechos de la atención psicológica. Lea
atentamente.

Toda la información suministrada por el evaluado será confidencial, con uso

exclusivamente académico incluyendo todo material de carácter audiovisual, al igual que
toda actividad a realizar con el candidato se desarrollara bajo fundamentación teórica que
será explicada con claridad durante la ejecución de pruebas o terapia a realizar. Se aclara al
candidato o tutor, que si en algún momento desea no continuar con el proceso, está en todo
su derecho de hacerlo.

Conozco que seré sometido a una serie de pruebas y entrevistas psicológicas por uno o
varios estudiantes de psicología pertenecientes a la corporación universitaria Minuto de
Dios, los cuales me han suministrados información clara y precisa sobre el tipo de pruebas
que se me practicaran y las entrevistas a realizar, así mismo me han informado sobre la no
retribución de información inmediata sobre los hallazgos realizados por el o los estudiantes,
teniendo en cuenta que dicho material es de carácter investigativo. Se me informa que debo
suministrar algunos datos de carácter personal como historias clínicas y documentos de
interés.

Confirmo que he leído y comprendido la información que se encuentra en este documento

Nombre: ________________________________________ Firma: ___________________

C.C ________________________

Nombre del estudiante: ____________________________ Firma: ____________________

C.C ________________________
 BIBLIOGRAFÍA

Resolución 1995 de 1999: Normas para el manejo de la historia clínica. Diario Oficial No.
00.43655 del 5 de agosto de 1999. Hernández, G. (2012). Doctrina No. 03: El
Consentimiento informado en psicología, Doctrina del Tribunal Nacional
Deontológico y Bioético de Psicología