Ficha Clínica Plan de Tratamiento Integral de Adicción y Drogodependencia
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Transcript of Ficha Clínica Plan de Tratamiento Integral de Adicción y Drogodependencia
Ficha Clínica Plan de Tratamiento Integral de Adicción y Drogodependencia.
I. Datos Generales: Nombre Completo:_______________________________________________
Nº Ficha: __________________________
RUT: _____________________________
Edad:_____________________________
Escolaridad: _______________________
Estado Civil: ________________________
Domicilio: ______________________________________
Ocupación: _____________________________________
Teléfonos: ______________________________________
Origen Derivación: _________________________________________________
________________________________________________________________
Motivo Consulta: __________________________________________________
________________________________________________________________
II. Cuadro clínico actual:
Sintomatología actual: ______________________________________________
________________________________________________________________
Inicio: ___________________________________________________________
Tratamientos anteriores: ____________________________________________
________________________________________________________________
Evolución:
________________________________________________________________
________________________________________________________
III. Antecedentes Psiquiátricos:
Tipo de cuadro o diagnóstico: ________________________________________
________________________________________________________________
Duración: ________________________________________________________
Tratamientos farmacológicos previos: _________________________________
________________________________________________________________
Internaciones previas: ______________________________________________
________________________________________________________________
IV. Antecedentes Mórbidos:
HTA: ____________________________________________________________
Endocrinos: ______________________________________________________
Gastrointestinal: __________________________________________________
Neurológicos: _____________________________________________________
Traumatismos: ____________________________________________________
Otros: ___________________________________________________________
V. Antecedentes de intentos de Suicidio:
________________________________________________________________
________________________________________________________________
VI. Antecedentes psicosociales familiares:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
VII. Genograma:
VIII. Examen mental:
Conciencia:_______________________________________________________
________________________________________________________________
Psicomotilidad:____________________________________________________
________________________________________________________________
Afectividad:_______________________________________________________
________________________________________________________________
Lenguaje:_________________________________________________________
________________________________________________________________
Pensamiento:_____________________________________________________
________________________________________________________________
Sensopercepción:__________________________________________________
________________________________________________________________
Inteligencia:______________________________________________________
________________________________________________________________
IX. Historia de Abuso de sustancias:
Tipo de sustancias:_________________________________________________
________________________________________________________________
Antecedentes Familiares de consumo__________________________________
________________________________________________________________
X. Diagnósticos DSM IV-R:
Eje I:____________________________________________________________
Eje II:____________________________________________________________
Eje III:___________________________________________________________
Eje IV:___________________________________________________________
Eje V:____________________________________________________________
XI. Conciencia de enfermedad y nivel motivacional:
1.-______________________________________________________________
2.-______________________________________________________________
XII. Puntajes Test psicológicos:
Personalidad:_____________________________________________________
____________________________________________________________
Suicidalidad:______________________________________________________
______________________________________________________________
OQ 45.2:_________________________________________________________
________________________________________________________________
Craving:__________________________________________________________
_______________________________________________________________
XIII. Plan de tratamiento:
Psiquiátrico/
farmacológico_____________________________________________________
________________________________________________________________
_____________________________________________________
Piscoterapéutico___________________________________________________
________________________________________________________________
________________________________________________________________
Intervención Familiar_______________________________________________
________________________________________________________________
________________________________________________________________
Intervenciones Grupales____________________________________________
________________________________________________________________
________________________________________________________________
Psicoeducación____________________________________________________
________________________________________________________________
________________________________________________________________