Wiki Independent Historian: Spouse

[jeburke23]

I'm currently reviewing a case where a new patient is downplaying the severity of his current issue, infection of big toe, and denying any other current health issues to the provider. His wife is documented as stating that the patient has diabetes and high blood pressure, has had several cases of non-compliance with his diabetic and blood pressure medication as well as sudden unexplained weight loss along with the reason for the visit.

Would the patient's wife be considered an independent historian at this point due to her providing this information? The patient does not have any type of cognitive delays only an unwillingness/stubbornness to acknowledge his current state. Which is what has caused my hesitation to consider the wife as an independent historian.

 

[csperoni]

Yes, I would consider the wife an independent historian in this situation. If the clinician determined the additional input from the spouse was necessary for any reason, that would meet independent historian.
Here is the AMA definition with my emphasis added.
►Independent historian(s): An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It does not include translation services. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

 

[amyjph]

I would probably count this. It would have a big impact on the care and treatment too.

p.s. I used to live near Hayesville Lovely place.