History Taking: Flashcards
history taking
why is history taking important?
Ascertain child’s development, health and previous medical history
* Significant changes in hearing or health
* Rapport building
* Appropriate testing strategy
* Family engagement
* Patient management: discharge or regular follow ups needed?
* Observing the child and their interactions with their family members or carers
* You may lose the child’s attention!
- so you can take notes
how does it look like?
- introduce yourself. ask name and relationship with child.
- Outline structure of appointment.
- if a child is active, test then take history.
- ask carer “what’s main reason for coming today? ask if they know about a referral if it is a referral.
what to do during history?
observe child and ineteractions.
assess the Childs cognitive ability to perform chosen hearing test (VRA/play)
areas to cover in history?
- school/education
- general health
- pregnancy history and birth history
- concerns for hearing?
- speech and language history
- family history
- general development
what questions would you ask about hearing?
- any ringing/buzzing in the ear?
- parental concerns?
- play/group/school have any hearing concerns?
- how does your child respond to sounds at home? do they respond at a distance.
speech and language?
any parental concerns?
do they babble their words?
do they have exposure to multiple languages?
clarity of speech?
vocabulary size?
can they express their needs?
family history of HL?
1) Any person have it?
2) cause of it?
3) HL Previously investigated?
general health?
- recent cold and coughs?
- ear infection, pan, discharge?
- previous ear problems?
-signifigant medical history?
-any long term medication with ototoxic effect.
-VP shunt?
-illness? disorders? syndroms?
pregnancy?
- how long carry?
- complications during child’s birth?
- special care baby unit?
- medication for drug or birth?
newborn hearing results?
concerns about speech and language development, what would you do?
find any concerns? speech and language development?
are they exposed to language?
refer
child has developmental delays? what further information would you do or obtain? how can this impact testing?
does pqeaditricina know? to what extent is delays? can you test them? is there an underlying cause or syndrome?
Autism Spectrum Disorder? how does it impact your appointment, room set up, conduction of test?
- find out what their development delays are.
- adapt to their needs
- what does the child like?
why is report writing important?
accurate log of key of information. provides guardians with a summary of appointment, you can update the healthcare professionals and referrer.
contraindications of good history?
- acute medical emegrnecies
- language or communication barriers
- child in severe stress or pain
- no guardian who knows a god history or known no knowledge
-time restraint in critical situation
What is the correct layout of paediatric report writing?
- Title and Header (child’s name, date of assessment and audiologist details)
- Introduction: “provide context (reason for referral brief medical history”
- Assessment: Describe tests performed (e.g., otoscopy, tympanometry, audiometry). Include results for each frequency tested.
- Results Interpretation: Clearly state the findings (e.g., “hearing within normal limits bilaterally”).
- Conclusion and Recommendations: Summarize the outcome (e.g., discharge, referral to other services).
6.Contact Information: Offer follow-up details for further queries.
