Assessment > Psychiatric Interview > History of Presenting Complaint

Presenting Complaint

This is a record of the patient’s view as to why they are seeing you and is usually recorded in the person’s own words.

 

Begin with open questions:

  • “What is it you would like us to help you with?”

  • “Could you describe the problems you have been having recently?”

  • “Why do you think your GP has sent you to see us?”

History of Presenting Complaint

 

  • Patient’s current symptoms and the onset of the current concerns - “When did you last feel well?” or "When did these difficulties start" can be helpful.

 

There is often the need to narrow the questioning and define the current episode in terms of dates or symptoms, e.g. “So this has been going on for about three months, would that be about January?" or "So you have been feeling low/unsafe/anxious, how long has that been going on for?".

 

  • Chronological order of symptoms

 

  • Onset, duration and changes over time - Asking open and then closed questions regarding their severity and duration documented along with predisposing and relieving factors.

 

  • Effect on social life / circumstances, occupational, personal functioning and self-care.

 

  • Life events / stressors, alcohol or drug misuse or non-compliance with prescribed interventions.

 

  • Suicidal thoughts and actions must be asked about in every patient assessed.

 

  • In all patients there must be an assessment of mood, anxiety and psychotic symptoms to inform the mental state examination.