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The focus of this question is how do we obtain patient history if the source is not the patient. We should always try to obtain the information from the patient first. An elderly person may have dementia, hearing, or vision loss. Specifically, greater than 50% of elderly will have presbycusis, a hearing loss of higher tones (Bickley, 2021). To remedy this, we can speak in a lower voice, avoid distractions such as the medical record and speak face to face with the patient. To further aid in communication, hearing amplifiers can be used. The patient should also be encouraged to speak with their dentures in so we may understand them more clearly. We can confirm what the patient says with the person’s caregiver and family if available   The same is true for infants and children. We may also have a medical record to review and other physicians to consult depending on the location. Additionally, there are special assessment tools like APGAR scores for infants and developmental quotients (developmental age/chronological age x 100) that can be used all ages and the mentally disabled (Bickley, 2021). More special development tools are the Modified Checklist for Autism in Toddlers, Early Language Milestones Scale, and Parents Evaluation of Developmental Status (Bickley, 2021). These tools have been shown to be more effective in determining the appropriate development of the patient than a comprehensive history.

Resource

Bickley, L.S. (2021).  Overview:  Physical examination and history taking.  Bates’ guide to physical examination and history-taking, 13th ed.   New York:  Lippincott, Williams, & Wilkins. ISN-13:9781496398178


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