History : History Fundamentals
The history process is often divided into three separate parts. Generally, building rapport occurs first, and an individual history directly from the child or non-offending parent/caregiver may be obtained in whichever order makes the most sense, determined on a case-by-case basis. Within each part, key elements must be included. This should include assessment of the child’s understanding regarding why they are being examined, determination of the safety of the child and other family members, and development of a timeline and outline of what happened. The goals listed above can be addressed using different questions and approaches for each part of the history.
Building Rapport
Both the child/adolescent and the parent/caregiver need to trust their medical provider in order to provide complete information, agree to the physical examination, and be open to the therapeutic experience that the visit can provide. Building rapport begins as soon as you interact with them. The techniques are the same as those used during regular, routine checks and are especially important before a physical examination related to abuse. Rapport building continues with each person individually during the taking of the history from that person. With both the parent/caregiver and child/adolescent present, rapport building provides a good opportunity to ask about (and respond to) any concerns regarding the medical evaluation process. Understanding their fears and emotional state can help you to create a positive experience. In addition, this is an opportunity to assess both parent/caregiver and child/adolescent expectations and provide reassurance, if possible.
Taking a history from the non-offending parent/caregiver without the child/adolescent present
After a brief time with all the family members (and caregivers) together, in most cases you will move to the next part of the history: taking a history from the parent/caregiver. Reassure the child/adolescent that you will be talking with him/her shortly. Provide supervision for young children while they are separated from the parent/caregiver. If both parents are present, if possible, obtain a history from each separately. In some situations, you may not be able to separate the parent/caregiver and child. In those situations, it is important to recognize that the parent/caregiver should not provide the same level of detail and that communication in front of the child could impact how the child responds to future questions. This is true for adolescents as well. In this case, questions may need to be brief and specific to the assessment of immediate medical needs.
The Purpose of Taking This History
- Obtaining a complete pediatric history to determine if there are other medical issues or conditions
- Obtaining as complete a picture of the abuse as the parent/caregiver can provide
- Giving the parent/caregiver an opportunity to express their feelings about the abuse and address concerns
- Assessing the level of support the parent/caregiver can provide the child/adolescent
- Providing education about the abuse investigation and legal process
To do this well, the parent/caregiver needs to feel free to talk with the medical provider privately.
Taking a history directly from the child/adolescent
Every effort should be made to obtain this history without other family members present.
Because the medical record may be used as evidence in a legal proceeding, it is important to document responses accurately.
The Purpose of Taking This History
- Ensuring recognition of the child’s/adolescent’s autonomy
- Allowing the opportunity for the child to discuss any fears they may have about the examination
- Allowing the child/adolescent to discuss what happened in their own words
- Enabling discussion of medical concerns directly with the child/adolescent
- Giving the child/adolescent the opportunity to express their feelings about the abuse or other concerns Assessing whether the patient is a mature minor. For information about Consent by Mature or Emancipated Minors, see LEGAL ISSUES: Consent
- Assessing the child’s/adolescent’s general cognitive abilities, mental state, psychiatric concerns
To prevent confusion and misinterpretations, avoid jargon in questions and abbreviations when documenting. It is extremely important to document what was said about the abuse, using the person's own words. In addition, record who was in the room at the time, the question preceding any disclosures, and the emotional affect and reactions of the parent/caregiver and child/adolescent when talking about the abuse. For a more complete explanation of good documentation, see DOCUMENTATION: Documenting the History.
