Start with the person’s account #
Ask what brought the person now, what troubles them most and what help they want. Begin openly, then clarify symptoms and their effect on work, relationships, self-care and daily activities. Identify language, communication and sensory needs.
Build a timeline #
Anchor onset, changes, treatment and recovery to memorable events. Distinguish persistent traits from episodes and establish functioning between episodes. Ask about previous mood elevation when assessing depression; examine substances, medicines and medical events in the same timeline.
Use collateral thoughtfully #
State who supplied each important account, their opportunity to observe and any disagreement. Seek consent and follow applicable confidentiality requirements. Missing collateral creates uncertainty; it does not establish that a symptom is absent.
Turn history into a formulation #
Separate vulnerability, recent triggers, maintaining factors and supports. Explain which findings support the working formulation, which alternatives remain and what further assessment would resolve them. Avoid assigning a diagnosis from a single symptom, appearance or scale score.
Close with an agreed next step #
Summarize the concern in accessible language, check the person’s understanding and document preferences and unresolved questions. Record the clinician’s agreed plan, review arrangements and escalation advice in the appropriate clinical record.
Use in practice
References · 1
- Nitin Sethi, Psychiatric history taking · Supplied PDF pages 9, 10. PDF locators; not a claim of original print pagination.