This is the fourth post in a series that highlights standardized formats for your clinical notes. The series began here.
A third format for clinical note taking is commonly known as BASIC SID. This is yet another mnemonic. The letters stand for Behavior, Affect, Sensation, Imagery, Cognition, Spiritual (and Religious), Interpersonal, and Drug (and Biology).
Behavior refers to what you see your client doing and not doing.
Affect refers to both your client’s mood and congruence with expressing those moods.
Sensation refers to your client’s awareness of his five senses and includes hallucinations, perceptual illusions, muscular tension or pain, excessive sensitivity to environmental stimuli, and what the client saw and heard.
Imagery related to your client’s past, present or future in any way includes dreams, fantasies, obsessions, flashbacks and responses to guided imagery.
Cognitive focuses on your client’s constructed meaning i.e. self talk, mental abilities, personal narrative, beliefs and mental schema.
Spiritual includes your client’s beliefs related to a Supreme Being, affiliation and practices with religious groups, religious resources, conscience and moral development, themes of guilt and forgiveness, creativity, and personal comfort related to ideas of spirituality.
Interpersonal references your client’s relationships with others, level of social skills, degree of acculturation, and any incidents of social injustices.
Drug and biological includes your client’s use of chemicals (both illegal and legal), medical compliance and concerns, and any incidents of delirium or dementia.
What I really like about a BASIC SID clinical note is that the acronym provides prompts to help me remember to focus on all areas relevant to my client’s progress.
Tomorrow I will talk to you about taking clinical notes using the Gillman HIPAA Progress Note.