Comprehensive Health Assessment

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 criteria found in KM Competency A–KM2, KM3 and KM8 as possible and are listed below. 

Cultural Characteristics (KM2-C)

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/gender identity, education level, social support.


Communication Needs (KM2-D)

The team identifies whether the patient has specific communication requirements due to hearing, vision or cognition issues (language needs are assessed in KM10).


Family History (KM2-A)

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 use disorder, hypertension) for first-degree relatives. If patients do not know their family medical history, this should also be documented.


Advance Care Planning (KM2-I) (NA for pediatric practices)

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 Affecting Health (KM2-E)

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.


Mental Health and Substance Abuse Family and Patient History (KM2-B)

Students assess whether the patient and the patient’s family has mental health/behavioral conditions or substance use issues (e.g., stress, alcohol, prescription drug misuse, illegal drug use, maternal depression).


Developmental Screening for Pediatric Patients using a Standardized Tool (KM2-H)

For newborns through 30 months 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.


Depression Screening for Adults and Adolescents (KM3)

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.


Assessment of Health Literacy (KM8)

The student team assesses the patient/family/caregiver’s ability to understand the concepts and care requirements associated with managing their health.