Internal Code – MAS3993
Obtain a brief description of the principal complaint and the time frame of the problem in the individual’s own words. The individual’s concerns need to be taken seriously. Respect and empathy will enhance trust. The individual’s description of the problem will also enable the clinician to assess the individual’s description of the problem and will also enable the clinician to assess the individual’s insight or perception into his or her situation. Specifically, find out:
• What is the nature of the problem?
• Why and precisely how has the individual presented / at this time?
• What events led up to this presentation?
• Who else is involved?
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