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.

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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).

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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