Pediatric Informatics: Computer Applications in Child Health (Health ...

5 Special Health Information Needs of Adolescent Care 45
privacy against adequate care and/or public health reporting mandates. Clinicians
treating teens may often be faced with these conflicts when handling patient data.
Computerized prompting systems, 3 screening questionnaires, 4 and automated
health assessments 5 address some of these barriers and have been shown to improve
services for adolescents.
5.3 Core Clinical Data
In addition to knowledge of transitional developmental issues into adulthood and
general health issues of teens and developing adults, providers of primary and specialty
adolescent health care must collect, record, and communicate:
Biological data
Vital signs, growth parameters, and physiologic measures in contrast to normal adult
values (blood pressure, heart rate, weight, body-mass index, electrocardiogram)
Anatomic, physiologic and physical maturity (sometimes including: bone age),
parental heights, musculoskeletal strength, endurance and performance
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Sexual maturity rating (Tanner scores, both genders), gonadal endocrine
functions (including laboratory parameters, both genders), physical examination
normal findings
Obstetric/gynecologic data (gravidity, parity, menstrual parameters)
Medical history (including hospitalizations, surgeries, medications, allergies)
Physical findings suggesting risky behavior (constitutional, skin, oral/dental)
Disease-specific findings, diagnoses, and therapies
Genetics and family history (hypertension, asthma, hyperlipidemia, diabetes)
Psychological data
Cognitive and intellectual functions, including intelligence, language, and
literacy/numeracy
Affective functions, including depression, suicidal ideation
Social data
School achievement and job readiness/performance
Legal and economic status, including emancipation, homelessness, marital, and
insurance status
Cultural data
Religion and effects on health care preferences
Customs and culture-specific health practices
Sexuality data
Gender, orientation
Practices (including contraception and high risk sexual experiences)