Descriptions
Comprehensive health assessment includes (all items required):
A. Medical history of patient and family.
B. Mental health/substance abuse history of patient and family.
C. Family/social/cultural characteristics.
D. Communication needs.
E. Behaviors affecting health.
F. Social functioning.
G. Social determinants of health.
H. Developmental screening using a standardized tool. (NA for practices with no pediatric population under 30 months of age)
I. Advance care planning. (NA for pediatric practices)
A comprehensive patient assessment includes and examination fo the patient's social and behavioral influences in addition to a physical health assessment. The practice uses evidence-based guidelines to determine how frequently the health assessments are completed and updated. Comprehensive, current data on patients provides a foundation for supporting population needs.
As part of the comprehensive health assessment the practice:
a. Collects patient and family medical history (e.g., history of chronic disease or event [e.g., diabetes, cancer, surgery, hypertension]) for patient and "first-degree" relatives (i.e., who share about 50% of their genes with a specific family member).
b. Collects patient and family behavioral health history (e.g., schizophrenia, stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).
c. Evaluates social and cultural needs, preferences, strengths and limitations. Examples include family/household structure, support systems, and patient/family concerns. Broad consideration should be given to a variety of characteristics (e.g., education level, marital status, unemployment, social support, assigned responsibilities).
d. Identifies whether a patient has specific communication requirements due to hearing, vision, or cognition issues. (Note: this does not address language; refer to KM 10 for language needs).
e. Assesses risky and unhealthy behaviors that go beyond physical activity, alcohol consumption and smoking status and may include nutrition, oral health, dental care, risky sexual behavior and secondhand smoke exposure.
f. Assesses a patient's ability to interact with other people in everyday social tasks and to maintain an adequate social life. May include isolation, declining cognition, social anxiety, interpersonal relationships, activities of independent living, social interactions and so on.
g. Collects information on social determinants of health: conditions in a patient's environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include availability of resources to meet daily needs; access to educational, economic and job opportunities; public safety, social support; social norms and attitudes; food and housing insecurities; household/environmental risk factors; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation (Healthy People 2020).
h. For newborns through 30 months, uses a standardized tool for periodic developmental screening. If there are no established risk factors or parental concerns, screens are done by 24 months.
i. Documents 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 an advance directive on file will meet the requirement.