From the Guidelines
The correct way to document that a patient cannot provide family history is to clearly state in the medical record that the family history is unknown or unavailable, along with the specific reason why this information cannot be obtained. This approach is crucial for maintaining accurate and comprehensive medical records, as highlighted in guidelines for managing patients with complex medical conditions, such as those infected with HIV 1. When documenting the inability to obtain family history, it's essential to provide a specific reason, such as:
- Patient adopted with no knowledge of biological family
- Patient unable to provide due to cognitive impairment
- Patient estranged from family members
- Patient has limited knowledge of family medical conditions
- Patient unconscious or critically ill This documentation helps other healthcare providers understand that the information was sought but genuinely unavailable, rather than overlooked during the assessment. By including the reason for the unavailability of family history, healthcare providers can better assess the patient's risk factors and make informed decisions about their care, as family history information is valuable for risk assessment and diagnostic considerations 1.
From the Research
Documenting Inability to Provide Family History
- There are no direct research papers that provide guidance on the correct way to document that a patient cannot provide a family history.
- However, studies have shown the importance of genetic counseling and testing in various diseases, including Huntington's disease 2, dementia 3, 4, and neurodegenerative diseases 5.
- These studies highlight the need for effective communication and risk disclosure, but do not specifically address the documentation of a patient's inability to provide a family history.
- One study on genetic counseling content and its impact on health behavior 6 suggests that the content of genetic counseling can influence health behaviors, but does not provide guidance on documenting a patient's inability to provide a family history.