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formato de historia clinica, Lecture notes of Clinical Medicine

Universidad del Sagrado Corazón (USC)Clinical Medicine
Prof. Rubi Salas

formato de historia clinica de psiquiatria completo.

Typology: Lecture notes

2024/2025

Uploaded on 06/11/2025

dasha-leyton-nunez
dasha-leyton-nunez 🇺🇸

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MODELO DE HISTORIA CLÍNICA PSIQUIÁTRICA
HISTORIA CLÍNICA
1. Filiación:
- Nombre: …………………………………………………………………………………………
- Fecha de Nacimiento: ………………………………………………………………………
- Edad: ……………………………………………………………………………………………..
- Sexo: ……………………………………………………………………………………………..
- Religión: …………………………………………………………………………………………
- Estado Civil: ……………………………………………………………………………………
- Ocupación: …………………………………………………………………………………….
- Grado de Instrucción: ……………………………………………………………………….
- Lugar de Nacimiento: ……………………………………………………………………….
- Procedencia: …………………………………………………………………………………..
- Dirección: ……………………………………………………………………………………….
- Persona a quien acudir: …………………………………………………………………….
- Fecha de Ingreso: …………………………………………………………………………….
- Fecha de elaboración de la historia: ……………………………………………………
2. Motivo de consulta:
3. Historia de la enfermedad actual:
4. Antecedentes:
a. Psiquiátricos:
b. Médicos
Enfermedades:
pf3
pf4
pf5

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MODELO DE HISTORIA CLÍNICA PSIQUIÁTRICA

HISTORIA CLÍNICA

  1. Filiación:
    • Nombre: …………………………………………………………………………………………
    • Fecha de Nacimiento: ………………………………………………………………………
    • Edad: ……………………………………………………………………………………………..
    • Sexo: ……………………………………………………………………………………………..
    • Religión: …………………………………………………………………………………………
    • Estado Civil: ……………………………………………………………………………………
    • Ocupación: …………………………………………………………………………………….
    • Grado de Instrucción: ……………………………………………………………………….
    • Lugar de Nacimiento: ……………………………………………………………………….
    • Procedencia: …………………………………………………………………………………..
    • Dirección: ……………………………………………………………………………………….
    • Persona a quien acudir: …………………………………………………………………….
    • Fecha de Ingreso: …………………………………………………………………………….
    • Fecha de elaboración de la historia: ……………………………………………………
  2. Motivo de consulta:
  3. Historia de la enfermedad actual:
  4. Antecedentes: a. Psiquiátricos: b. Médicos Enfermedades:

Intervenciones quirúrgicas: Medicamentos: Alergias: c. Hábitos Nocivos: Uso de Alcohol y otras sustancias

  1. Historia Personal: a. Prenatal y Perinatal: b. Niñez Temprana: c. Niñez Intermedia: d. Adolescencia:

Examen Mental

  1. Apariencia, Porte, Comportamiento y Actitud
  2. Psicomotricidad
  3. Afectividad: Estado de Ánimo, Afecto
  4. Pensamiento: Curso, Contenido
  5. Sensopercepción
  6. Conciencia
  7. Memoria: Inmediata, Reciente, Remota
  8. Calculo Básico:
  9. Atención y Concentración
  1. Juicio
  2. Introspección Otros Estudios diagnósticos: Diagnóstico: