The first seven items may be included on a summary sheet at the front of the medical record. The information should, ideally, be obtained at the first office visit. The components of a comprehensive pediatric history are listed in Table 9–1. When an allergy with potential for anaphylaxis is identified, the patient should wear a medical alert bracelet and obtain an epinephrine kit, if appropriate. A second page documenting immunizations should record data required by the National Childhood Vaccine Injury Act. Some practices keep track of health supervision visits on this sheet to tell the physician whether the child is likely to have received the appropriate preventive services. Use of a summary sheet such as this at the front of the chart or the electronic medical record facilitates reorienting the caregiver and his or her partners to the patient. Documentation of immunizations, including all data required by the National Childhood Vaccine Injury Act, should be kept on a second page.įigure 9–1. Demographic data a problem list information about chronic medications, allergies, and previous hospitalizations and the names of other physicians providing care for the patient are commonly included. In absence of an electronic medical record, such information can be accumulated on a summary sheet, as illustrated in Figure 9–1. However, failure to review and assimilate this information prior to the interview may cause a parent or patient to feel that the time and effort have been wasted.Įlements of the history that will be useful over time should be readily accessible in the medical record. Developmental and mental health screening saves provider time and the results when reviewed with the parent or family member can yield critical information. Questionnaires may be more productive than face-to-face interviews in revealing sensitive parts of the history. Data from questionnaires can make an outpatient visit more productive, allowing the physician to address problems in detail while more quickly reviewing areas that are not of concern.
Many offices provide questionnaires for parents to complete before the clinician sees the child. Obtaining a comprehensive pediatric history is time consuming.
Direct histories not only provide firsthand information but also give the child a degree of control over a potentially threatening situation and may reveal important information about the family. Understanding the family and its hopes for and concerns about the child can help in the process of distinguishing organic, emotional, and/or behavioral conditions, thus minimizing unnecessary testing and intervention.Īlthough the parents’ concerns need to be understood, it is essential also to obtain as much of the history as possible directly from the patient. Parents may or may not be able to distinguish whether symptoms are caused by organic illness or a psychological concern. Parents and patients may provide a specific and detailed history, or a vague history that necessitates more focused probing. Obtained data was analyzed by SPSS software.A unique feature of pediatrics is that the history represents an amalgam of parents’ objective reporting of facts (eg, fever for 4 days), parents’ subjective interpretation of their child’s symptoms (eg, infant crying interpreted by parents as abdominal pain), and for older children their own history of events. Because ASQ is designed to use for 4-60 month- old children, children who were out of this rang were evaluated by developmental pediatricians. In order to determine the agreement coefficient, these children were also evaluated by ASQ test. At developmehtal a precise translation of test was done by three specialists in Pcf literature and then it was revised by three pediatricians familiar with developmental domains. The test covers four functions: gross motor, language, fine motor-adaptive, and personal-social.
The Denver Developmental Screening Test (DDST) was devised to provide a simple method of screening for evidences of slow development in infants and preschool children. Uji Denver II dilakukan pada usia 4-6 bulan. Sosial dipakai dalam skrining pada Denver Developmental Screening Test (DDST) dan. Started in 1995, this collection now contains 6806 interlinked topic pages divided into a tree of 31 specialty books and 736 chapters. is a rapid access, point-of-care medical reference for primary care and emergency clinicians.
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