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.
Gathering
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).
|
 
|