Which statement about Category 2 assessment for limited data is correct regarding an independent historian?

Which statement about Category 2 assessment for limited data is correct regarding an independent historian?

• A. For limited data, the independent history must be obtained in person.
• B. For limited data, the independent history does not need to be obtained in person but must be obtained directly from the historian providing the information.
• C. For limited data, independent historians are not used.
• D. For limited data, the independent history can be obtained from any source.

Answer: (B)

In Category 2 assessment with limited data, an independent historian is someone other than the patient who provides history about the patient. The important point is that the history from this independent source must be obtained directly by you, the clinician, rather than relayed through the patient or someone else. It doesn’t have to be an in-person interview; you can obtain it through direct communication such as a phone call or teleconference, as long as you have direct contact with the historian and gather the information firsthand. For example, if a patient has cognitive impairment and a family member provides crucial history, you should speak directly with that family member to obtain the history and document that direct contact occurred. Simply accepting information that was filtered through the patient would not meet the requirement. The other options don’t fit because they either unnecessarily restrict the mode of contact (in-person only), claim independent historians aren’t used, or allow indirect or generic sourcing without direct, first-hand communication.

In Category 2 assessment with limited data, an independent historian is someone other than the patient who provides history about the patient. The important point is that the history from this independent source must be obtained directly by you, the clinician, rather than relayed through the patient or someone else. It doesn’t have to be an in-person interview; you can obtain it through direct communication such as a phone call or teleconference, as long as you have direct contact with the historian and gather the information firsthand.

For example, if a patient has cognitive impairment and a family member provides crucial history, you should speak directly with that family member to obtain the history and document that direct contact occurred. Simply accepting information that was filtered through the patient would not meet the requirement.

The other options don’t fit because they either unnecessarily restrict the mode of contact (in-person only), claim independent historians aren’t used, or allow indirect or generic sourcing without direct, first-hand communication.