CLIN ED II @andretaleon

PEDIATRIC DOCUMENTATION School-age o Directly interview and

can participate in their
Sir Adriane Tuminez, PTRP health care
o Health providers can
APPROACH TO CHILD & ADOLESCENT ASSESSMENT role model for parents
Role of Pediatric Provider as they engage the
• Collaborator with the Parents child in the health
• An advocate to protect and care for the child interview.
Adolescents o Interviewed separately
Setting o Engage independently.
• Child-friendly
• Exposure to crying and upset children should be Effective Communication
avoided in the waiting room • Question indirectly
• Examination room should have small table and o Ex. “Some 15 y.o have tried marijuana.
chair with toys for different ages Do you have any friends who smoke
• “Lose the white coat” marijuana?”
• Pictures of cartoon characters or animals on the • Pose scenarios
wall to create playful atmosphere. o “What would you do if …..?” → Young
child
Establishing a Caring Relationship o “How would you feel if .....?” → Older
• Listen actively to the concerns of the family school-age and adolescents
• Understand the family expectations for the • Begin with less threatening topics
encounter o Ex. “Tell me how things are going to
• Ask open-ended questions school this year.”
• Personalize your care • State your expectations clearly
• Learn and understand the importance of cultural o “I need for you to be very quiet now so I
values in the family can listen to ….” → Child
• Identify protective factors in the family that create o “To take care of you, I need for you to
a positive environment for the child tell me …” → Adolescent.
• Build a sense of confidence in parents by • Do not offer a choice
confirming and complimenting their strengths in • Use “I”
caring for their child. • Ask the preschool or young school-age child to
draw a picture.
Parents and Child Interaction
• Analyze verbal response “Quiet to Active” Approach
• Observe the nonverbal cues • Quiet: PR, RR, Auscultation.
• Active: the rest.
Interviewing Children
• Eye-level encounters Developmental Approach
• Initially directing attention to the parent or Age Group
caretaker allows the infant or toddler time to
Preterm o Limiting body heat loss and
adjust to the environment and interviewer
Infants and stabilizing T°
• Talking-through formal – decrease anxiety Newborns o Initially: parent’s arm
• 3y.o. can effectively participate in the health o Observe the movements of the
interview. newborn, overall appearance, skin
color, breathing pattern and degree
Age Group Interview Style of alertness or responsiveness
Preschool o Ask about their o Physical examination is performed
activities, playmates, between the eating and sleeping
and school or childcare cycles of the newborn
o Engage them in Infants 4-6 o Quet: parent’s arm
discussion of health mos o Active: firm surface table
history issues o Calm gentle approach
o Never leave the examining table

MIDTERM 1
CLIN ED II @andretaleon

Infants - o Eye contact: stranger anxiety APGAR SCORE

Toddlers o Quiet: Parent’s lap, knee-to-knee
position
o Active: examining table
Preschoolers o They are able to make eye contact
(3 y.o) and separate briefly from the
parent
o Observe their ability to be
comforted, evaluate their response
to the environment, their level of
social interaction, and their
relationships with
parents/caretakers and siblings
o Quality and variety of verbal
response, level of activity and
attention span COGNITIVE DEVELOPMENT
o Respond best to slow, even,
steady voice
o Give them clear directions, allow
them to respond, and recognize
success
o Enjoy games, drawing and role-
playing.
School age o Talk-through approach
o Interested in learning about their
bodies and are forming an image of
themselves
o Becoming more independent from
their parents
o Offer them choices about who will
be present in the exam room
o Respect modesty and allow the
child to participate in the exam
room
Adolescent o Respect and confidentially are
essential
o Should be interviewed and
examined separately
o Avoid power struggles and give
them control
o Involve them in planning and
establishing health habits.

DEVELOPMENTAL MILESTONE
• The key milestone are divided into four (4)
descriptive areas of development:
o Gross Motor
o Fine Motor Adaptive
o Personal/Social
o Speech and Language
Along with two other descriptive areas:
o Cognitive
o Emotional

MIDTERM 2