Patient Record in SRH Care and Risk Assessment

This tool contains a record of care registration and also a risk assessment. The file is a form where the information of the integral consultation is consigned and that consists of several sections: personal data; data of the physical evaluation carried out in the pre-consultation; the questionnaire for risk assessment; the results of the evaluation and the referrals. This form can be adapted in a digital form. This is used by the Basic Teams of Integral Health Care in Costa Rica as part of their computer system. The risk assessment is carried out by means of a questionnaire included in the Record of Care Registration (in the part below) that includes three dimensions: social dissension, mental health and sexual and reproductive health. The results of this evaluation determine the follow-up actions to the adolescent person to respond to their specific needs. This tool must be used during the provision of basic integral care.