The guidelines state "A decision to obtain old records or decision to obtain additional history
from the family, caretaker or other source to supplement that obtained
from the patient should be documented." (emphasis by me) In your situations the history from the parents is the only history you have so you aren't really getting additional history.
The fact most of your history is going to come from someone other than the patient in pediatrics is just the nature of the beast in my opinion.
Laura, CPC, CEMC
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