Section B: Getting to Know the Person's Story
Admission and Personal History: Key Information for a Comprehensive Assessment
Dear Colleagues, Dear Nursing Professionals,
We are continuing our monthly tour through the sections of the interRAI HCSvizzera manual.
After taking an in-depth look at Section A, which is dedicated to administrative data and the reason for the assessment, we will now focus on Section B: Intake and History.
Although this section contains only a small amount of information, it provides important clues for understanding the person’s history prior to their current care.
What information does Section B contain?
Section B addresses two main aspects:
the person’s citizenship;
their housing history over the past five years.
This is not merely descriptive data. This information helps place the current situation within the context of a broader personal, housing-related, and care history.
Citizenship: Record Without Interpreting
Citizenship must be accurately recorded and documented, using the information provided by the person and, if necessary, available supporting documents.
It is important not to automatically associate nationality with information that has not been directly verified. Nationality, language, cultural customs, and care needs do not necessarily correspond.
The coding must therefore reflect the information provided without transforming it into an interpretation of the person or their situation.
Living Situation Over the Past Five Years
The current living situation has already been addressed in Section A. Section B, however, broadens the perspective and reconstructs the environments in which the person has lived over the past five years.
Situations to be considered may include:
Long-term care facilities;
Assisted living facilities or facilities for partially independent individuals;
Residential facilities for people with mental health issues;
Hospitals or psychiatric wards;
Facilities for people with intellectual disabilities.
For each setting listed on the form, indicate whether the person lived there during the period in question.
Why should the last five years be considered?
The person’s housing history can help to better understand the following:
previous levels of independence;
previous experiences with support services;
transitions between living independently and living in facilities;
any complex needs that have emerged over time;
resources or difficulties that have emerged in different contexts.
This information must not be used to draw automatic conclusions. Rather, it serves as a starting point for delving deeper into the person’s history and interpreting their current situation more thoughtfully.
A Common Mistake
A person currently lives in their own home and receives in-home care. However, three years ago, they spent some time in a long-term care facility.
Section A documents the current living situation. Section B should also include the previous living situation, since it occurred within the five-year period under consideration.
Limiting the record to only where the person lives today means omitting an important part of their history.
What sources should be used?
The person themselves should be the primary source of information, whenever possible. The following sources may also be consulted to supplement or verify the history:
Family members or significant others;
clinical and administrative records;
information from previous facilities or services.
If conflicting information comes to light, it is necessary to investigate it further and document the most reliable information without relying on assumptions.
Would you like to learn more about using interRAI HCSvizzera?
In our Italian-language courses, Esther Chapman guides healthcare professionals through the use of the tool—from the correct collection of information to coding and evaluating results, all the way to care planning.
On our website, you’ll find the current calendar and information about the upcoming interRAI-HC courses.
Understanding a person’s history helps us understand their present and plan more informed care.
Swiss Chapman Consulting SAGL
