Comprehensive Health Status Note Components

Essential Components

The American Academy of Pediatrics recommends including patient demographics and identification, such as name, address, telephone number, and additional contact information, in a comprehensive health status note 1, 2
The American Academy of Pediatrics suggests documenting age and weight as part of the patient's demographics 2
The American Academy of Pediatrics recommends including the name of the patient's personal care provider or medical home in the health status note 1
Vital signs, including heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature, should be documented, as recommended by the American Academy of Pediatrics 1, 3
The American Academy of Pediatrics advises documenting if vital signs cannot be obtained due to patient non-cooperation 1

The American Academy of Pediatrics recommends documenting allergies and previous allergic or adverse drug reactions, as well as medication history, including prescription medications, over-the-counter medications, herbal supplements, and illicit drugs 2, 3
Relevant diseases and physical abnormalities should be documented, according to the American Academy of Pediatrics 2, 3
Pregnancy status should be documented for females of childbearing age, as recommended by the American Academy of Pediatrics 3
The American Academy of Pediatrics suggests documenting history of seizure disorders and previous relevant hospitalizations 3

The American Academy of Pediatrics recommends focusing on abnormalities of cardiac, pulmonary, renal, or hepatic function during the review of systems 2, 3
Specific query regarding signs and symptoms of sleep-disordered breathing or obstructive sleep apnea should be documented, as advised by the American Academy of Pediatrics 3
The American Heart Association recommends documenting symptoms related to the presenting condition 4, 5

A focused evaluation of body systems relevant to the patient's condition should be performed, as recommended by the American Academy of Pediatrics 1, 3
The American Academy of Pediatrics suggests assessing airway, including tonsillar hypertrophy, abnormal anatomy, or other factors that might increase risk of airway obstruction 1, 3
Physical status evaluation, including ASA classification for procedural cases, should be documented, according to the American Academy of Pediatrics 1

The American Academy of Pediatrics recommends documenting positive findings noted during evaluation and formulating a management plan 1, 6
For hospitalized patients, a note documenting that the chart was reviewed should be included, as advised by the American Academy of Pediatrics 1, 6

The American Heart Association recommends documenting symptom burden, functional status, and health-related quality of life 7, 8

The American Academy of Pediatrics suggests including a copy of the prescription or note describing content for prescribed medications 1, 6
Instructions given to the responsible person regarding medications should be documented, as recommended by the American Academy of Pediatrics 1, 6

For procedural documentation, a time-based record of administered drugs, including name, route, site, time, dosage, and patient effect, should be documented, as advised by the American Academy of Pediatrics 1, 9
The American Academy of Pediatrics recommends documenting "time out" confirmation of patient name, procedure, and site 1, 9
Monitoring data, including level of consciousness, responsiveness, and vital signs, should be documented, according to the American Academy of Pediatrics 9

The American Academy of Pediatrics advises against failing to document when vital signs cannot be obtained due to patient non-cooperation 1
Omitting medication history that could interact with treatments should be avoided, as recommended by the American Academy of Pediatrics 2, 6
Inadequate documentation of allergies and previous adverse reactions should be avoided, according to the American Academy of Pediatrics 2, 3
The American Heart Association recommends against not documenting baseline health status for comparison during treatment 7, 8

Record any adverse events that occur during a procedure and describe the treatment administered to manage those events, as recommended in pediatric procedural safety guidelines 10, 11.