Components of a Health Status Note
A comprehensive health status note should include a detailed health evaluation with vital signs, physical examination findings, review of systems, medical history, and a management plan to ensure proper patient care and monitoring.
Essential Components
Patient Demographics and Identification
- Patient's name, address, telephone number, and additional contact information 1
- Age and weight 1
- Name of patient's personal care provider or medical home 1
Vital Signs
- Heart rate 1
- Blood pressure 1
- Respiratory rate 1
- Room air oxygen saturation 1
- Temperature 1
- Document if vital signs cannot be obtained due to patient non-cooperation 1
Health History
- Allergies and previous allergic or adverse drug reactions 1
- Medication/drug history including dosage, time, route, and site of administration for:
- Relevant diseases and physical abnormalities 1
- Pregnancy status for females of childbearing age 1
- History of any seizure disorders 1
- Summary of previous relevant hospitalizations 1
- History of previous treatments and any complications or unexpected responses 1
- Relevant family history, particularly related to medical conditions 1
Review of Systems
- Focus on abnormalities of cardiac, pulmonary, renal, or hepatic function 1
- Specific query regarding signs and symptoms of sleep-disordered breathing or obstructive sleep apnea 1
- Documentation of symptoms related to the presenting condition 1
Physical Examination
- Focused evaluation of body systems relevant to the patient's condition 1
- Assessment of airway (if relevant) including tonsillar hypertrophy, abnormal anatomy, or other factors that might increase risk of airway obstruction 1
- Physical status evaluation (ASA classification for procedural cases) 1
Assessment and Management Plan
- Documentation of positive findings noted during evaluation 1
- Formulated management plan 1
- For hospitalized patients, a note documenting that the chart was reviewed 1
Patient-Reported Health Status
- Documentation of symptom burden 1
- Functional status (physical, mental/emotional, and social function) 1
- Health-related quality of life (patient's perception of their health) 1
Medication Documentation
- For prescribed medications, include a copy of the prescription or note describing content 1
- Instructions given to the responsible person regarding medications 1
Special Considerations
For Procedural Documentation
- Time-based record of administered drugs including name, route, site, time, dosage, and patient effect 1
- Documentation of "time out" confirmation of patient name, procedure, and site 1
- Monitoring data including level of consciousness, responsiveness, and vital signs 1
For Post-Procedure Documentation
- Time and condition of the patient at discharge 1
- Documentation that the patient's level of consciousness and oxygen saturation have returned to a safe state 1
Common Pitfalls to Avoid
- Failing to document when vital signs cannot be obtained due to patient non-cooperation 1, 2
- Omitting medication history that could interact with treatments 1
- Inadequate documentation of allergies and previous adverse reactions 1
- Not documenting baseline health status for comparison during treatment 1
- Relying solely on traditional vital signs without considering additional assessments like pain, level of consciousness, and urine output in critically ill patients 2
Additional Assessments to Consider
- Pain assessment as a "fifth vital sign" 2
- Level of consciousness for patients with altered mental status 2
- Urine output monitoring for critically ill patients 2
- Pulse oximetry as a valuable addition to traditional vital signs 3
By including these components in a health status note, clinicians can ensure comprehensive documentation that supports effective patient care, facilitates communication among healthcare providers, and establishes a baseline for monitoring patient progress 1, 3.