Wiki Independent Historian?

[ssharp]

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?

 

[lcolborn]

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.

 

[csperoni]

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.