The comprehensive health and developmental history is a required EPSDT component and an important tool in providing effective health care.

The history can be used to build a carefully documented record of a child's health and development, from the neonatal period through the milestones of early and middle childhood and the changes and challenges of adolescence.

Contents of the Health and Developmental History A comprehensive history includes: Birth History (for children 5 years and younger) Complete family and social history Physical, mental, and developmental history Immunizations and screenings Review of body systems

Gathering information and identifying concerns and risk factors in the limited time available for a well-child visit is a developed skill.

Providers who show genuine interest in the child and family, ask perceptive questions, and listen thoughtfully can create a trusting and reassuring atmosphere in which the child and family will begin to relax, feel comfortable, and share more about their concerns and other important issues.

Documenting the Health and Developmental History

Thoroughly document all aspects of the health and developmental history using the Standard Medical Record Form (SMRF) (link opens in new window).

Specific Areas of Note in Filling Out the SMRF (from SMRF training):

History/Parent Concerns (2 month to 21 years): must check box next to interval history OR write in text on lines below.

Social/Family History: should be reviewed with patient/guardian and checked when completed.

Read more about Documentation Required for Compliance with HealthCheck (link opens in new window).

(Note: this image is taken from SMRF #5: 2 to 5 year old visits; forms for other age ranges may differ slightly).