D117 Advanced Health Assessment Documentation Form

D117 Advanced Health Assessment Documentation Form

Patient Demographics and Vital Signs

What are the key demographic details and vital signs to be documented?

Comprehensive documentation of patient demographics and vital signs establishes the clinical foundation for an advanced health assessment. Demographic information allows healthcare providers to accurately identify the patient while also recognizing sociocultural, biological, and personal factors that may influence health behaviors, risks, and outcomes. Recording elements such as age, sex assigned at birth, gender identity, race or ethnicity, and preferred pronouns supports culturally competent and patient-centered care.

Vital signs reflect the patient’s current physiological status and provide essential baseline data for clinical comparison. Measurements such as temperature, heart rate, respiratory rate, blood pressure, height, weight, and body mass index (BMI) assist clinicians in identifying deviations from normal ranges, monitoring disease progression, and evaluating treatment effectiveness.

Chief Complaint and History of Present Illness (HPI)

What is the patient’s main concern and current illness history?

The chief complaint identifies the primary reason for the healthcare visit and is ideally recorded using the patient’s own words to preserve accuracy and intent. This concise statement directs the clinical focus and prioritizes assessment needs.

The history of present illness (HPI) provides an in-depth, chronological narrative of the presenting problem. It explores symptom onset, duration, anatomical location, severity, quality, precipitating and relieving factors, and associated manifestations. A thorough HPI enhances diagnostic reasoning, ensures continuity of care, and supports evidence-based clinical decision-making.

Medications and Allergies

Which medications and allergies should be documented?

Medication reconciliation is a critical safety practice requiring documentation of all prescription medications, over-the-counter drugs, herbal products, and dietary supplements. Each entry should include the medication name, dosage, route, frequency, and therapeutic purpose to prevent adverse drug events and interactions.

Allergy documentation must clearly distinguish true hypersensitivity reactions from side effects or intolerances. Accurate recording of allergens and associated reactions is essential to prevent life-threatening complications and guide safe treatment planning.

Allergies and Reactions:
All known allergies should be listed with a clear description of the patient’s reaction (e.g., rash, anaphylaxis, gastrointestinal upset).

Past Medical History (PMH)

What elements should be included in past medical history?

Past medical history contextualizes the patient’s current condition by outlining previous diagnoses, chronic illnesses, hospitalizations, and surgical interventions. Including approximate dates improves clinical accuracy and longitudinal tracking.

Immunization status is a vital component of PMH, reflecting adherence to preventive care guidelines. Documentation of influenza, pneumococcal, and tetanus vaccinations assists in identifying gaps in protection and guiding preventive counseling.

Family History

How should family history be recorded?

Family history identifies hereditary and genetic predispositions that may increase the patient’s risk for certain diseases. Conditions such as cardiovascular disease, hypertension, diabetes, cancer, and autoimmune disorders should be documented for first- and second-degree relatives.

Each condition should be associated with the specific family member affected, along with their current age or age at death. This information supports risk stratification, screening recommendations, and preventive interventions.

Personal and Social History

What social and personal factors affect health?

Personal and social history explores lifestyle behaviors, environmental exposures, and psychosocial factors that significantly influence health outcomes. Substance use, physical activity, dietary patterns, and safety behaviors provide insight into modifiable risk factors.

Additional domains such as education level, literacy, occupation, financial stability, access to healthcare, transportation, technology, and social support systems contribute to a holistic understanding of the patient’s lived experience. Religious beliefs, hobbies, and sexual history may also affect healthcare preferences and risk profiles.

Review of Systems (ROS)

How is the review of systems conducted and documented?

The review of systems is a systematic inquiry into major body systems to identify symptoms not previously disclosed. Both positive and negative findings should be documented to demonstrate assessment completeness.

Positive responses require further elaboration and correlation with the HPI or medical history. A comprehensive ROS enhances diagnostic accuracy and reduces the risk of missed conditions.

Physical Examination

What observations and system examinations are important during physical assessment?

The physical examination consists of objective findings obtained through inspection, palpation, percussion, and auscultation. General observations include appearance, orientation, posture, mobility, speech, mood, affect, and hygiene.

Systematic evaluation of all major body systems ensures accurate identification of abnormalities. Neurological assessment includes cranial nerves I–XII, motor and sensory function, coordination, reflexes, and evaluation for meningeal signs.

Focused Orthopedic Examination

How are specific orthopedic tests documented?

A focused orthopedic examination assesses joint stability, muscle strength, ligament integrity, and nerve involvement based on the patient’s presenting symptoms. Each test should be documented with the anatomical area evaluated, clinical rationale, and outcome to support diagnostic conclusions.

References

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). ANA.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer.

Course Hero. (2025). Advanced health assessment documentation form (D117). Adapted from course materials.