Factual documentation about the Patient-Member, including the Patient-Member’s:

• Diagnosis
• Behavioral and/or Physical symptoms
• Appearance
• Orientation
• Mood/Behavior
• etc

How does the Patient-Member present themselves?

• Affect
• Behavior
• Eye Contact
• Nervousness
• Talkativeness

All of this is based on your Observations.

As the Health Manager/Medical Advisor, what are your observations?

What measurable data is available or are you using?

What observable data is available or are you using?

What is going on with the Patient-Member at the moment?

For example:

Is the Patient-Member crying? Having trouble making eye contact? Bleeding? 

Is the Patient-Member disheveled? 

Does the Patient-Member appear to have not showered or shaved in the last 2+ days?