Patient Profile

This is the opening section of the patients' notes it establishes the socio-demographic profile and the reason and source of referral. Much of this information can be obtained from referral letters / notes - however asking the patient directly can be a good way to get the interview started.

The details you need to obtain are: -

• Full name

• Age

• DOB

• Marital / relationship status

• Occupation

• Racial/ethnic origin

• Religion

Demographics are often filled in at the top of a history sheet but it is useful to have an opening paragraph summarising who the patient is and setting the scene for the rest of the history. This section should set the scene for the reader giving an idea 'about the patients place in society.' [1]

Example. Rory 'Mr. Rory Hamish Kilbride is a 58 year old, white Irish gentleman. He is married to Martha with whom he has one 14 yr old son. He also has two children from his previous marriage (wife deceased). He works part time at a bookshop in London. He has been a practicing the kabbala faith for the past 4 years. Mr. Kilbride was admitted under section after being found naked and disorientated in phone box trying to set fire to a kabbala book. He was arrested and taken to the police station before being transferred to the A&E at the local psychiatric hospital.'

1. Zaman, R., Makhdum, A. Churchill's Pocketbook of Psychiatry. Churchill Livingstone., 2000, pp. 35