Pediatric Health Assessment

THE PEDIATRIC HEALTH ASSESSMENT HISTORY Obtaining a complete history of a pediatric patient not only is necessary but also leads to the correct diagnosis in the vast majority of children. The history usually is learned from the parent, the older child, or the caretaker of a sick child. After learning the fundamentals of obtaining and recording historical data, the nuances associated with the giving of information must be interpreted. For the acutely ill child, a short, rapidly obtained report of the events of the immediate past may suffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary. A convenient method of learning to obtain a meaningful history is to ask systematically and directly all of the questions outlined below. After confidence is gained with experience, questions can be problem-directed and asked in an order designed to elicit more specific information about a suspected disease state or diagnosis. Some psychosocial implications will be obvious. More subtle details often are obtained by asking open-ended questions. Those with organic illness usually have short histories; those with psychosomatic illness have a longer list of symptoms and complaints. During the interview, it is important to convey the parent's interest in the child as well as the illness. The parent is allowed to talk freely at first and to express concerns in his or her own words. The interviewer should look directly either at the parent or the child intermittently and not only at the writing instruments. A sympathetic listener who addresses the parent and child by name frequently obtains more accurate information than does a harried, distracted interviewer. Careful observation during the interview frequently uncovers stresses and concerns that otherwise are not apparent. The written record is not only helpful in determining a diagnosis and making decisions but also is necessary for observing the growth and development of the child. A well-organized record facilitates the retrieval of information and obviates problems if it is required for legal review. The following guidelines indicate the information needed. If preferred, several printed forms are available, that contain similar material, or forms may be modified as long as consistency is maintained. General Information Identifying data include the date, name, age, birth date, sex, race, referral source if pertinent, relationship of the child and informant, and some indication of the mental state or reliability of the informant. It frequently is helpful to include the ethnic or racial background, address, and telephone numbers of the informants. Chief Complaint After the identifying data, the chief complaint should be recorded. Given in the informant's or patient's own words, the chief complaint is a brief statement of the reason why the patient was brought to be seen. It is not unusual that the stated complaint is not the true reason the child was brought to attention. Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.