如何使用 Claude 作為治療師的文件記錄助手:Sophia Skill 指南

Updated
Skill · .md · 可搭配 Claude 與 ChatGPT 使用
Sophia - 治療師與諮商師 AI Skill
Sophia - 治療師與諮商師 AI Skill
$14.99這項 Skill 相較於 $100治療師的每小時費率

供合資格治療師使用的文件記錄輔助工具 - Sophia 起草符合治療取向的會談紀錄、治療計畫框架及執業文件,而每份文件都由你審閱並簽署。可搭配 Claude、ChatGPT 或任何 AI 聊天工具使用。

查看 Sophia →

繁忙的治療工作,每位客戶的一小時會談可能需要撰寫 30 到 45 分鐘的紀錄 - 會談紀錄、治療計畫、信件、執業行政文件。這些文書工作不可或缺,也令人疲憊,還會消耗治療師投入實際工作的精力。以Claude 作為治療師的文件記錄助理為設計理念,旨在減輕這項負擔:像 Claude、ChatGPT 或任何 AI 聊天工具,能協助具備資格的治療師更快速地起草符合治療取向的會談紀錄、治療計畫框架及執業文件。它支援臨床工作者進行文書整理 - 不會提供治療,而它起草的每份文件都必須由臨床工作者審閱、個人化並簽署。

重要:這項 Skill 適用於哪些人

這是一款供具備資格並完成註冊的治療師與諮商師使用的專業工具,用於協助文件記錄。它不會提供治療、諮商或心理健康建議,也不適合尋求個人支援的人。如果你正感到困擾或痛苦,請聯絡合資格的專業人士、你的家庭醫生或當地支援服務 - 文件工具不是適合處理這些情況的地方,而你值得獲得真正的人性支援。以下所有內容都是為臨床工作者自身的文書工作而寫,所有臨床判斷仍由臨床工作者自行負責。

符合你治療取向的會談紀錄

CBT 紀錄使用的語言,和 EMDR 或以人為中心取向的紀錄不同。在起草前,這項 Skill 會先詢問你採用的治療取向,接著根據你提供的內容,以治療師實際使用的格式 - SOAP、DAP、BIRP 等類似格式 - 產生會談紀錄框架。你提供臨床內容;它負責架構與撰寫整理。

治療計畫與執業文件

除了會談紀錄之外,這項 Skill 還能起草治療計畫框架、初次評估架構、治療結束信,以及每位私人執業臨床工作者都會處理的執業行政文件 - 合約、隱私聲明、取消政策。這些是供你調整的起始框架,不是可以不閱讀就直接使用的完成文件。

審閱後起草 - 絕無例外

會談筆記是具法律效力的臨床紀錄。Skill 產出的所有內容都是供合格臨床人員閱讀、修正、個人化並簽署的草稿。任何涉及風險的內容都需要臨床人員自行評估並完成 - Skill 提供的是框架,絕不是完成的風險評估。紀錄的責任始終由治療師承擔。這與我們醫學寫作者指南中的臨床寫作內容相輔相成。

內建機密性

此 Skill 設計為使用 [CLIENT] 等佔位符,而非識別資訊;對於可輸入任何工具的內容,您應遵循專業團體的倫理規範、GDPR 及資訊治理義務。個案機密是這項工作的基礎,優先於任何節省時間的效益。

為什麼 Skill 勝過一次性 prompt

載入的 Skill 包含您的治療模式、筆記格式及執業場所的慣用風格,因此每份草稿都保持一致,您也不必在每次會談中重新說明結構 - 對於需要處理大量個案的人非常實用。如需了解相鄰醫療專業的文件處理,請參閱我們的 醫療相關專業指南

誠實的限制

此 Skill 會根據您記錄的內容起草文件;它無法評估個案、做出臨床判斷,也不知道您未告訴它的任何事情,而且它不是治療、督導或臨床建議。建立在不完整記錄上的流暢筆記,仍然是不完整的。請將它視為負責處理結構與起草工作的文件助理,而每項臨床決策、每次風險評估及最終簽署的紀錄,則由您負責。以這種方式使用 Claude 作為治療師的文件助理,能將數小時的文書時間還給真正有助於個案的工作。

相關 Skill 指南

常見問題

Can I use Claude as a therapist for myself?+

No, and it is worth being specific about why rather than just saying no. A chat window is a place to write at any hour, and it can help you put words to something, draft what you want to tell a GP, or explain a term. What it cannot do is the part that matters: it agrees with the account you bring, so if you describe a situation in the shape your distress has given it, you get a thoughtful reply built on that shape that sounds like understanding. A therapist notices what you did not say and is willing to disagree with you about your own story. It also has no continuity, cannot see you getting worse over weeks, is not accountable, and cannot act. If you are thinking about harming yourself, contact your local emergency services or a crisis line in your country today.

What is this skill actually for?+

Documentation, for qualified and registered therapists and counsellors. It drafts modality-appropriate session notes in formats such as SOAP, DAP and BIRP from your own post-session account, plus treatment-plan frameworks, intake structures, ending and referral letters, and practice documents. It does not provide therapy, counselling or mental-health advice, and every document it produces is a draft for the clinician to correct, personalise and sign.

Can AI write my session notes?+

It can reformat your own account into your note format, which is where the time actually goes. It must not add anything. The instruction that makes this safe is to forbid inference: use only what the clinician wrote, mark any required field with nothing behind it as NOT RECORDED rather than filling it, and never upgrade an observation such as seemed tired into clinical language. A note that reads more confidently than you remember the session is a liability rather than a time saving.

Can AI complete a risk assessment?+

No, and this is the hardest line on the page. Risk assessment is clinical judgement with consequences, and a model will draft one fluently if you let it. A blank framework for the clinician to complete is the furthest this goes. A useful instruction in any note prompt is that if the account touches on risk, the model writes RISK: CLINICIAN TO COMPLETE and says nothing further.

Is it safe to put client information into an AI chat?+

Settle this once, before the workflow rather than inside it. Your professional body's ethical framework, your information-governance obligations and, in the UK and EU, GDPR treatment of special category data all bear on it, and the answer depends on your tier, your agreements and your jurisdiction. Practices that work regardless: draft from CLIENT placeholders, leave out dates of birth, addresses and identifying circumstances, and remember that a rare presentation plus a small town identifies someone as surely as a name does. If you are employed, this is a question for your information-governance lead first.

Who is responsible for a note drafted by AI?+

The clinician, without qualification. A session note is a legal clinical record. The model handles structure and prose; the clinician supplies every piece of clinical content, checks the draft against what actually happened, and signs it. Nothing about using a drafting tool changes professional or legal responsibility for the record.

What does it get wrong most often?+

Fluency that outruns your recollection, and quiet clinical upgrades where an observation becomes a diagnosis or a passing remark becomes a theme. It is also agreeable: ask whether a note is adequate and you will be told yes, so ask instead what a supervisor or an auditor would query. And it blends jurisdictions, since record-keeping requirements, retention periods and what a letter may contain differ by country, professional body and service.

Is this a substitute for clinical supervision?+

No. Nothing here replaces supervision, and using a chat as a place to think through a difficult case is a different activity from drafting a note, with different confidentiality implications that should be considered separately.

~/get-started

實用的 Skills。不說空話。

瀏覽商店中的每個技能、prompt 套件和 agent。

瀏覽所有技能 →或試試免費工具