# Independent Historian?



## ssharp (Feb 4, 2021)

In pediatrics what qualifies as an Independent Historian? 
Example: 
patient is here today for sick visit with complaint of Not eating or drinking, irregular BM for 4 days patient is seen with father! (can i count that as assessment requiring independent historian)

But: We often do have older children that come with their selves and give information and it states patient seen with self. Am i reading correctly that this does not count since it is only the patient giving the information?


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## lcolborn (Feb 4, 2021)

Having a minor is not automatic credit for independent historian . You have to state who is  providing the history . " Mom is providing the history , Guardian is providing the information , etc. ". 
And no, it does not count if the minor patient is able to tell the story or the problem. Any credible person other than the patient ,  providing information or additional information that helps in the assessment and plan is considered an independent historian.


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## csperoni (Feb 4, 2021)

Exactly - you can only get credit for independent historian IF it's documented, and required/necessary.  
You clearly don't get it in your example, but the clinicians should receive education about documentation requirements so you are not missing data points moving forward that are being done, just not properly documented.
With younger children, most likely if the father was there, the father added information provided by patient (# of days, etc).  Note the words "patient is UNABLE", "REQUIRING an independent historian", and "judged to be NECESSARY."  So a 16 year old who gives complete details is very different than a 7 year old who needs a parent/guardian to clarify how many days they have been sick, or what their temperature was.  An interjecting parent who is re-iterating exactly what the 16 year old said, it not required or necessary.  

*Independent  historian(s):*  an  individual  (eg,  parent,  guardian,    surrogate,  witness)  who  provides  a  history  in  addition  to  a  history  provided  by  a  patient  who  is  unable  to  provide  a  complete  or  reliable  history  (eg,  due  to  developmental  stage  or  loss  of  consciousness)  or  because  a  confirmatory  history  is  judged  to  be  necessary.  In  a  case  in  which  there  may  be  conflict  or  poor  communication  between  multiple  historians  and  more  than  one  historian  is  needed,  the  independent  historian(s)  requirement  is  met.


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