Presenting complaint and chronology

Establish a baseline and timeline

Begin with what the person considers the main difficulty and the reason help is being sought now. Identify the last period of usual functioning, the earliest change and the sequence of subsequent symptoms. Approximate dates can be useful when exact recall is difficult; state that they are estimates.

Separate onset, course and current severity. A problem may start gradually but fluctuate later, or begin abruptly and then persist. Describe the actual sequence before applying labels such as episodic or continuous. Do not assume that a duration threshold from an older teaching handout is a current diagnostic rule.

Connect symptoms with everyday life

Explore sleep, appetite, energy, self-care, work or study, social participation and responsibilities. Identify what has become harder, what has stopped and what is still maintained with additional effort. Functional detail makes the account more informative than a general statement that the person is impaired.

For each important symptom, establish its setting, triggers, frequency and consequences. Ask for examples in everyday language and clarify what the patient or informant actually observed. Relevant absent symptoms should reflect questions that were asked, rather than a copied negative-history list.

Place treatment and contributors on the same timeline

Add physical illness, medication exposure, substance use, life events and treatment contacts to the chronology. Record the reported benefit, difficulties and reasons treatment changed. A temporal association is useful evidence to examine; it does not by itself establish that one event caused another.

For your next supervision discussion

Build a timeline with symptoms, functional changes and treatment contacts in separate rows. Which events are dated confidently, which are approximate, and which relationships have been inferred rather than established?