A comprehensive health assessment includes an examination of social and behavioral influences, health risks and information needs of patients and/or families/caregivers. The student team obtains this information through a review of the patient’s medical record and through an interview with the patient and/or family/caregivers. The assessment should include as many of the elements found in Standard 3 Element C, Comprehensive Health Assessment as is possible and are listed below.
Immunization Status and Screenings that are age and gender appropriate (Factor 1)
- Easy to use CDC immunization schedules
- AHRQ Electronic Preventive Services Selector
- Bright Future Recommendations for Preventive Pediatric Health Care (American Academy of Pediatrics)
- Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) Quality Measures (select measure codes for the current year)
- Other U.S. Preventive Services Task Force Tools
- Children’s Health Care Quality Measures
- Women’s Preventive Services Guidelines
Cultural Characteristics (Factor 2)
The health assessment includes an evaluation of social and cultural needs, preferences, strengths and limitations. Examples of these characteristics can include:
- Family/household structure
- Support systems
- Household/environmental risk factors
- Patient/family concerns
Broad considerations should be made for a variety of characteristics e.g., poverty, homelessness, unemployment, sexual orientation, gender, education level, social support.
- HRET (Health Research & Educational Trust) toolkit for collecting race, ethnicity and primary language information from patients with specifics on how to ask questions on race, ethnicity, and primary language
- Think Cultural Health U.S. DHHS Office of Minority Health
- Think Cultural Health eLearning
- Consider Culture, Customs and Beliefs, AHRQ Tool #10
Communication Needs (Factor 3)
The team identifies whether the patient has specific communication requirements due to hearing, vision or cognition issues (language needs are assessed in Factor 2).
Family History (Factor 4)
The student team reviews and documents the relevant family history of the patient, including a history of chronic diseases or events (e.g., diabetes, cancer, substance abuse, hypertension) for first-degree relatives (who share about 50% of their genes with the patient). If patients do not know their family medical history, then this should also be documented.
- Family Health Portrait Toolkit U.S. Surgeon General
- Family Health History and Genetics Toolkit U.S. CDC
- Family Health History Toolkit Utah Department of Health
- 10 Questions to Ask Your Family
Advance Care Planning, if applicable (i.e., patient is an adult) (Factor 5)
The student team documents the patient/family preferences for advance care planning (i.e., care at the end of life or for patients who are unable to speak for themselves). This may include discussing and documenting a plan of care with treatment options and preferences. Patients with a recent advance directive already on file do not necessarily need this revisited. If a patient refuses or is a child, then documentation of this should be made.
Assessment of Behaviors that Affect Health (Factor 6)
Assessment of risky and unhealthy behaviors goes beyond physical activity and smoking status; it may include nutrition, oral health, dental care, familial behaviors, risky sexual behavior and secondhand smoke exposure.
- Keep ME Well Online Health Risk Assessment, Maine DHHS/CDC
- Health Risk Assessment U.S. CDC
- Appendix pages 43 - 50
- Medicare Wellness Checkup American Academy of Family Physicians
- Online Health Risk Assessment from Virginia Mason Medical Center
- AHRQ Adult Health Risk Assessment
- Bright Futures Children and Adolescents Screening Tools
Mental Health and Substance Abuse Family and Patient History (Factor 7)
Student assess whether the patient and the patient’s family has mental health/behavioral conditions or substance abuse issues (e.g., stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).
- National Institute on Drug Abuse Quick Screening Tool for use in General Medical Settings
- See Family History (Factor 4) and Depression Screening (Factor 9) for additional resources
Developmental Screening for Pediatric Patients using a Standardized Tool (Factor 8)
For newborns through 3 years of age, the student team should use a standardized test for developmental screening. If there are no established risk factors or parental concerns, screens are done by 24 months.
- Bright Futures Screening Schedule
- Bright Futures Pediatric Screening Tools
- Watch Me Thrive U.S. DHHS Developmental Screening Tools
Depression Screening for Adults and Adolescents (Factor 9)
Screening for adults: Screening adults for depression should take place when staff-assisted depression care support systems are in place to assure accurate diagnosis, effective treatment and follow-up. A standardized screening tool should be used (e.g., PHQ-9). A standardized tool collects information using a current evidence-based approach that has been developed, field-tested and endorsed by a national or regional organization.
Screening for adolescents (12–18 years): Screening for major depressive disorder (MDD) should take place when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal) and follow-up.
- U.S. Preventive Services Task Force Recommendations for Depression Screening in Adults
- PHQ-9 (9-question Patient Health Questionnaire)
- PHQ-2 (2-question)
- 15-Item Geriatric Depression Scale
Assessment of Health Literacy (Factor 10)
The student team assesses the patient/family/caregiver’s ability to understand the concepts and care requirements associated with managing their health.
- AHRQ Health Literacy Universal Precautions Toolkit
- Tools #4 (Communicate Clearly) and #5 (Teach-Back Method)
- More Detailed Health Literacy Measurement Tools AHRQ