Identifying Data
Includes age, gender, marital status, and occupation. The source of history or referral can be patient, a family member or friend, an officer, a consultant, or the medical record. Patients requesting evaluations for schools, agencies, or insurance companies may have special priorities compared to patients seeking care on their own initiative. Designating the source of referral helps you to assess the type of information provided and any possible biases.
Reliability
Should be documented if relevant. For example, “The patient is vague when describing symptoms and unable to specify details.” This judgment reflects the quality of the information provided by the patient and is usually made at the end of the interview.
Ramaz Mitaishvili, MD
