Patient Identification

• Confirm the patient's legal name, preferred name, and age

• Identify the patient's chief complaint and/or reason for seeking mental health treatment (if voluntary). 

"So Mr. Jones, what brings you here today? How can I be of help?"

If the patient was involuntarily admitted, ask the patient what happened and what they believe the reason is for involuntary commitment.

Chief Complaint

The chief complaint is documented in the patient's own words.

Example: "I've been really depressed the past few weeks."

History of Present Illness (HPI)

• Obtain a thorough History of Present Illness

The history of present illness is a narrative of events leading up to the visit or hospitalization. Ask about the onset, duration and severity of distressing symptoms and whether there are any factors (e.g., events or stressors) that are aggravating or alleviating the reported problem(s).