Get the facts of the illness/reason for interaction

Time and nature of the onset. 

Arrange facts in a chronological order 

Relate facts in a narrative fashion,

• tracing the course of events up to the time of the interaction. 

• What was done for Patient-Member?

• What drugs were given and what were the results of such treatment? 

• Pay special attention to recording “pertinent negative” data as well as positive information. 

• This includes physical exams, laboratory evaluations and treatments which occurred before the present interaction. 

• How has the illness affected the patient’s lifestyle? 

• Conclude with a description of the reason that resulted in the present interaction.