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.
- 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 (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.
- Family Health Portrait Toolkit U.S. Surgeon General
- Family Health History Resources for Health Professionals
- Family Health History Toolkit Utah Department of Health
- 10 Questions to Ask Your Family
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.
- 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
- Healthy Life HRA Health Risk Assessment
- AHRQ Adult Health Risk Assessment
- Bright Futures Children and Adolescents Screening Tools
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).
- National Institute on Drug Abuse Quick Screening Tool for use in General Medical Settings
- See Family History (KM2-A) and Depression Screening (KM3) for additional resources
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.
- Bright Futures Screening Schedule
- Bright Futures Pediatric Screening Tools
- Watch Me Thrive U.S. DHHS Developmental Screening Tools
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.
- 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 (KM8)
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) and #12 (Use Health Education Material Effectively)
- More Detailed Health Literacy Measurement Tools AHRQ