Wiki Historian

JParker5

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Hi, Would you accept "Mother is not sure about the sound of the cough, seem dry" as historian by Mom? Does the provider have to state History by or Mom stated? I don't want to be to hard. Thank you in advance.
 
I would accept it as assessment requiring an independent historian. Although I would like to see more context about the history behind the patient's presenting problem(s). Perhaps you can recommend to the provider moving foward to try and document more clarity.
 
To me, it would depend upon the patient’s age and whether the mom was providing additional info or acting as sole historian due to patient not being able to talk yet due to age (which I would not give credit for). But to answer your original question, if the person does qualify as an additional historian, I would normally think a statement like that came directly from the mom without it having to say “mom stated…”
 
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