HealthCheck Provider Education System

HealthCheck Training

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Overview

Health Supervision

Special Health Issues

Documentation

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Health Supervision

Health and Developmental History: Introduction

*The comprehensive health and developmental history is a required EPSDT component and an important tool in providing effective health care.

The history can be used to build a carefully documented record of a child's health and development, from the neonatal period through the milestones of early and middle childhood and the changes and challenges of adolescence.

 

Contents of the Health and Developmental History

A comprehensive history includes:

  • Birth History (for children 5 years and younger).
  • Complete family and social history.
  • Physical, mental, and developmental history.
  • Immunizations and screenings.
  • Review of body systems.

Mother and Child ImageGathering information and identifying concerns and risk factors in the limited time available for a well-child visit is a developed skill.

Providers who show genuine interest in the child and family, ask perceptive questions, and listen thoughtfully can create a trusting and reassuring atmosphere in which the child and family will begin to relax, feel comfortable, and share more about their concerns and other important issues.

 

Documenting the Health and Developmental History

  • History/Parent Concerns:
    • Newborn: Record a birth history; issues/complications during pregnancy (list medications, illnesses, drugs, ETOH); gestational age; birth weight; APGARS; complete a newborn history by 9 months.
    • All visits: Interval history completed? [yes/no; record comments]; list current medications.
  • Social/Family History:
    • For all visits: review social/family history with patient/guardian (or with teen for adolescent visits) and document. Completed? [yes/no; record notes].
    • Items of note: Record child care [yes/no/type] for 0-5 years; record preschool [yes/no] for 2-5 years. For 6-21 years, record comments on: home; education; emotional/behavior; exercise; activities/friends; diet/eating behavior; drug/alcohol/tobacco; sleep; sexual awareness/activity; abuse/violence; menarche; LMP.
    • Dental visit in last 12 months? [yes/no/record answer] (dental referral required yearly 3-21 years and at earlier ages if necessary).

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