Healthcare Research and Quality
Completing an infant or child health history always comes with the need for resources. Using the patient’s parent or guardian would be the first instinct to get a full health history. If the patient’s parent is not with them in person, I would call them to work to get the full history. If the patient is adopted or in state custody, I would try to get records to complete the history. Sometimes elderly patients cannot recall all their health history. Using a family member or caretaker is an option, also having the patients’ records sent from other offices, and using their medication list. Many times, in the area I work getting the patients medication list can help them to remember some of their health history. Also making sure to use language they understand as well as recalling all the systems. Asking them specific questions instead of generalized. For example: have you had any surgeries? Very general. “let’s start at the top have you had any head or face surgeries? Neck or shoulder? Thyroid or throat? “And continuing down. You can ask if the patient has a patient portal of history that you can see. But it is always important to ask the patient and then include the family or care giver in on the conversation. Patients with cognitive delays I would treat like a child or elderly making sure to ask them the questions but if they do not know refer to parent or guardian. Completing a history on a patient who speaks another language it is important to have a translator or language line. This is to make sure the patient can give the most accurate information and understand everything. Another useful tool is using a health history form. This could be given at the office or sent prior to the patients visit. The health history can be in multiple languages as well. The Agency for Healthcare Research and Quality (2020) has health literacy universal precautions tool kits that have forms for health histories. These could be helpful to help the patient, or their family get all the information prior to the visit also it maybe helpful to fill one out and just keep a copy if the patient can’t communicate or has memory problems. Another tool is asking questions and using verbal and non-verbal communication skills (U.S. Department of Health and Human Services, 2017).