Pontos comuns e estratégias para a escrita do psicólogo em prontuário único: relato de experiência

Abstract

Introduction: The growing insertion of Psychology in health environments demands technical adaptations to psychologists to work in multiprofessional contexts. One of the objectives of the Medical Record is to facilitate communication between professionals from different specialties, pointing out and describing the care process that the patient is going through. The Federal Council of Psychology states that the documentary record is mandatory on the provision of psychological services, but it presents vague and generalist guidelines, which ends up fomenting the production of multiple forms in the written reports produced by psychologists, that sometimes can be unclear. Objective: To describe the experience and developments of writing in the Medical Record at a multiprofessional residency in hospital care, from the perspective of the resident psychologist. Experience Report: The experience period happened during the first year of the residency, from March 2021 to February 2022. It is responsability of the resident to provide care from requests for opinions, spontaneous demands from patients, family members and/or informal caregivers, as well to promote active search with specific criteria. After each one, the activity must be recorded in the Medical Record. Conclusion: The intervention resulted in the production of a guiding structure for writing in the Medical Record, also becoming a topic addressed in the tutorials that took place as part of the training at the residency. At the same time, feedbacks were received from other multiprofessional teams about a greater ease in understanding the content recorded by psychologists.