Begin with ordinary language #
The presenting complaint records why the person sought or was brought for help. Preserve a short expression in their own words, then describe its duration. A complaint is not yet a diagnosis: 'anxiety' may refer to worry, panic episodes, restlessness or distress after an event. Family concerns may differ from the person's priorities; document both with attribution. Ask why help is sought now. A new consequence, referral or loss of support may explain the consultation better than symptom duration alone.
- What is the main difficulty from your point of view?
- What has changed that made you seek help now?
- Which problem began first? What was different before it started?
Build the timeline before interpreting it #
Anchor the last usual level of functioning, first change, additional symptoms, peak difficulty, help sought and current state. Approximate dates are acceptable if identified. Use examinations, festivals, moves or admissions as memory anchors without assuming a causal link. Clarify whether separate episodes were followed by full recovery, partial improvement or continuing difficulties. Onset, course and progress answer different questions; record them separately.
| Dimension | Question | Record |
|---|---|---|
| Onset | How quickly did the change develop? | Actual interval: overnight, days or months. |
| Course | Continuous or occurring in episodes? | Symptomatic periods and the state between them. |
| Progress | Compared with the beginning, better or worse? | Direction of change and evidence from function. |
Analyse each major symptom #
For each experience establish nature, onset, frequency, duration, severity, context and effect. Ask for a concrete recent example before assigning terminology. Determine what preceded an episode, what happened during it and what followed. Distinguish difficulty sleeping with tiredness from little sleep while feeling rested; these are different observations. Distinguish loss of enjoyment from lack of opportunity. Ask what improves or worsens the experience and whether it occurs across settings.
- Walk me through the most recent occasion, from beginning to end.
- How long did it last? How often has it happened this week?
- What did you think, feel and do at the time?
- What could you do before that has become difficult now?
- Does this occur only after a substance or medicine?
Associated features and everyday function #
Explore mood, fear, suspiciousness, unusual perceptions, energy, thinking, cognition and behaviour as indicated. Include sleep pattern, appetite, weight change, sexual function and physical symptoms when relevant. Assess self-care, study, work, household tasks, relationships and responsibilities to dependants. Specific examples are more informative than 'functioning impaired'. Ask directly about self-harm or harming others where clinically appropriate, and document answers and limitations rather than claiming risk has been ruled out.
- Attendance changed from five workdays weekly to one; establish illness effects and other causes.
- Stopped preparing meals; clarify motivation, money, concentration and practical support.
- Little sleep: distinguish time in bed, estimated sleep and daytime effects.
Contributors, exclusions and treatment #
Enquire about recent illness, injury, neurological symptoms, prescribed and non-prescribed medicines, substances and significant events. Record temporal relationships, exposure changes and previous similar states. A medical or substance-related explanation remains a hypothesis until assessed. Relevant negatives test particular alternatives; a standard list of denied symptoms does not exclude every differential. State what was asked, what was not assessed and why.
| Record | Useful detail |
|---|---|
| Intervention | Name or description, dose if known, duration and dates. |
| Benefit | Which symptoms or functions changed, and when? |
| Difficulties | Adverse effects, cost, access, understanding and preferences. |
| Discontinuation | Reason and relationship to later symptoms. |
Synthetic example: coherent chronology #
A fictional student reports concentration problems for six weeks. Classes were normal until a family illness eight weeks ago. Fragmented sleep began six weeks ago; attendance declined four weeks ago, followed by worry about examination failure. They describe fatigue, not increased energy. Caffeine increased after sleep difficulties began. This account identifies sequence and impairment without treating the stressor or caffeine as a proven cause. Examination, collateral information and assessment of mood, anxiety, physical health and substances remain necessary.
A useful closing summary #
End with baseline, duration, principal experiences, course, impact, treatment and unanswered questions. Preserve contradictions: a relative may date change earlier than the patient. Compare the current state with the whole episode; improvement today does not erase preceding impairment. A concise chronology lets another clinician understand what developed first and which facts would change the working interpretation. Check the timeline with the person and avoid implying that missing information is a negative finding.