Documentation in Counselling and Case History

Documentation in Counselling and
Case History
Name of the Learner: SAORABH
SHRIVASTAVA Enrolment no.: 185929627
Course Code: MPCE-025
Regional Centre: 15,
Bhopal
Study Centre: 1506, Govt. Holkar ByScience College, Indore
SAORABH SHRIVASTAVA / Enrolment no.185929627 /
Meaning of Documentation
 Paper work that provides an official information about the process of
counselling.
 It ensures Objectivity, consistent, meaningful expression of terms and conditions

between the counsellor and the counselee.
 Important for ethical and effective practice.
 Is a means of effective communication.
 Usually includes : Client Intake Form and Counselling Agreement.
By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

MPCE025
Client Intake Form
• The intake process is the foundation upon which the structure of the therapeutic
relationship is built.
• It includes important information about the counselee .
• Usually it is the counselee who fills this form, but if the counselee is unable to, the
counsellor can take charge of it.
• Usually includes a brief history, chief complaints and concerns of the client.
• It is filled prior to the counselling session.

MPCE025
Various kinds of Client Intake Form
• Intake form in Psychiatric settings
• Intake form in a counselling space
• Intake form in a hospital (General)
• Intake form in a rehabilitation centre

MPCE025
Essential Components
• Demographic Information: Name, Age, Gender
• Contact information: Phone, email id, address
• Brief Medical history as well as current medical problems
• Current medications
• Reason client is seeking counselling
• What does the counselee want to achieve from the current session
• Concerns, if any
MPCE025
Counselling Agreement
• A ‘counselling agreement’ is a mutual agreement between the counsellor and the
client in which the outline of the therapeutic alliance is presented.
• A counselling contract ensures that the counselling process will be performed in a

professional manner and highlights the responsibilities of the counsellor towards
clients, as well as the responsibilities of the client towards the counsellor.
• It clearly includes ‘Informed consent’.
• Is presented as a written document.
• It is not a lengthy document, usually a single page in length and contains a list of
items that are important for creating a safe, confidential and professional counselling
service. By SAORABH SHRIVASTAVA / Enrolment no.185929627 / MPCE025
Essential Components
• Nature of counselling work : a brief information about the therapeutic process.
• Where and when sessions will be held, For example once a week at Talk Remedies
Counselling space, Indore.
• Duration of the session: For example, 45 minutes to one hour.
• Fees and payment terms: how much the counselee needs to pay and possible
modes of payment.
• Cancellation/session rescheduling terms
• Information about confidentiality including unavoidable breach of confidentiality,

For example, in case of threat to self or others.
MPCE025
Important!
• It should include brief details about record keeping and method’s taken to
protect confidential data.
• Good choice of words
• Free of jargons
• Clear and concise
• Declaration
• Assistance: if the counselee is unable to understand it

MPCE025
Case History
 It is a method to gain in-depth information about someone or something.
 It is a planned professional conversation between the counsellor and the counselee

in which the counsellor asks a series of questions (open ended to closed ended) to
have a detailed understanding of the thoughts, feelings and symptoms of the
counselee.
 Gives insight into the nature and causal factors of the problems faced by the
client.
 It includes past medical, personal and family history.
 It is necessary for proper diagnosis and plan of treatment.

MPCE025
Methods
 Interview
Open ended: let the client talk about it in a free manner, sometimes even their daily
schedule. Usually in an organised manner : from present to past.
 Questionnaires
Used for gaining clear insight : For example, using GHQ for assessing general
health.
 Combination of both: in most of the cases.

MPCE025
Components
 Socio-Demographic information:
Name, Age, Gender, Occupation,  Family history
etc.
 Personal history
 Chief Complaints: sad mood, sleep
disturbance, etc.  Premorbid personality
 Nature of illness: onset, duration,  Mental status examination

etc.
 Diagnostic formulation
 History of present illness
 Past medical history

MPCE025
Mental Status Examination
 Is a structured assessment of the patient's behavioral and cognitive functioning.
 It includes descriptions of the patient's appearance and general behaviour,

level of consciousness and attentiveness, motor and speech activity, mood and
affect, thought and perception, attitude and insight among various observable
characteristics.
 Generally conducted at the end of the case history to avoid any kind of
intimidation for the patient.
 Is a marker of accuracy and sensitivity of the entire history.

MPCE025
Mental Status Examination
 Includes both objective observation of the psychologist and subjective description
given by the client. For example, “I don’t drink” is the client’s answer but you can
clearly smell it.
 Specific questions are asked and is not as detailed as a case history.
 It is quick and reliable.
 It provides information for diagnosis and assessment of the disorder.
 Do not confuse MSE with MMSE (test for dementia).

MPCE025
Components
 Appearance
 Behaviour
 Speech
 Mood and affect
 Thought process and content
 Cognition
 Insight and judgement

MPCE025
MPCE025
Case Formulation
 It is an important skill that helps us link the information obtained through case
history and MSE to the planning of treatment.
 Assessment Case Formulation Treatment Planning
 It includes the causes and triggering events for the problem.
 It answers WHY? For example, Why the person is facing this problem?
 Use of Biopsychosocial model

MPCE025
The 5 P’s of Case Formulation
 Presenting problem
 Predisposing factors : biopsychosocial factors contributing to the client’s problem
 Precipitants : triggering events
 Perpetuating factor: factors that maintain the problem
 Protective: client’s strengths

MPCE025
Components of Case Formulation
 State the problem (2-3 lines)
 State the 5 P’s in the same order
 Types of interventions used for this problem + client’s strength

MPCE025
Report Writing
 Important part of clinical practice
 Based on psychological assessments
 Diagnosis and Recommendations are included
 Brief and clear, usually not more than 3 pages

MPCE025
Components of Report Writing
 Demographics : important to include date of assessment
 A brief case summary
 Informed consent: one line without using this heading
 Assessments done : tests administered
 General test behaviour : cooperation, attention and concentration
 Overall findings: case formulation
 Treatment Plan/ Recommendations

MPCE025
Thank
You!!!
By SAORABH SHRIVASTAVA / Enrolment no.185929627 / MPCE025

Documentation in Counselling and Case History

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Documentation in Counselling and

 It ensures Objectivity, consistent, meaningful expression of terms and conditions

 Important for ethical and effective practice.

 Is a means of effective communication.

 Usually includes : Client Intake Form and Counselling Agreement.

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

• It includes important information about the counselee .

• It is filled prior to the counselling session.

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

• Intake form in a counselling space

• Intake form in a hospital (General)

• Intake form in a rehabilitation centre

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

• Contact information: Phone, email id, address

• Brief Medical history as well as current medical problems

• Reason client is seeking counselling

• A counselling contract ensures that the counselling process will be performed in a

• It clearly includes ‘Informed consent’.

• Is presented as a written document.

• Duration of the session: For example, 45 minutes to one hour.

• Cancellation/session rescheduling terms

• Information about confidentiality including unavoidable breach of confidentiality,

• Good choice of words

• Clear and concise

• Assistance: if the counselee is unable to understand it

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 It is a planned professional conversation between the counsellor and the counselee

 It includes past medical, personal and family history.

 It is necessary for proper diagnosis and plan of treatment.

 Combination of both: in most of the cases.

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 Nature of illness: onset, duration,  Mental status examination

 Past medical history

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 It includes descriptions of the patient's appearance and general behaviour,

 Is a marker of accuracy and sensitivity of the entire history.

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 Specific questions are asked and is not as detailed as a case history.

 It is quick and reliable.

 It provides information for diagnosis and assessment of the disorder.

 Do not confuse MSE with MMSE (test for dementia).

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 Mood and affect

 Thought process and content

 Insight and judgement

 Assessment Case Formulation Treatment Planning

 It includes the causes and triggering events for the problem.

 Use of Biopsychosocial model

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 Predisposing factors : biopsychosocial factors contributing to the client’s problem

 Precipitants : triggering events

 Perpetuating factor: factors that maintain the problem

 Protective: client’s strengths

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 State the problem (2-3 lines)

 State the 5 P’s in the same order

 Types of interventions used for this problem + client’s strength

By SAORABH SHRIVASTAVA / Enrolment no.185929627 /

 Important part of clinical practice

 Based on psychological assessments

 Diagnosis and Recommendations are included

 Brief and clear, usually not more than 3 pages