A comprehensive health assessment is a systematic collection and analysis of information related to a patient's health, including information about social determinants of health. Most practices already capture data on the patient's medical history and family history, as well as on care that has been provided. However, practices should also be capturing information about a patient's family, social, and cultural characteristics and communication needs if they are not already doing so.
Practices can use the time prior to appointments (such as in the waiting room) or during the clinical intake with assistance from the medical assistant or nurse to have patients and families review and update this information.
Although there is no "standard" comprehensive health assessment, most practices determine the information to include based on its patient population, and develop a template for use. Alternatively, existing tools can be modified to fit a practice's needs. To improve practice workflow, the health assessment tool should be integrated into the practice's EHR system in a seamless way.
2a. Document the patient's family, social and cultural characteristics
Collect, understand and regularly update the patient's family, social and cultural characteristics. 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, and patient/family concerns. Broad considerations should be made for a variety of characteristics (eg, poverty, homelessness, sexual orientation, gender, social support).
2b. Document the families/patient's communication needs.
Collect, understand and regularly update the communication needs of the patient and family. Your practice should identify and document whether the patient or family has specific communication requirements due to limited English proficiency (LEP), or hearing, vision or cognition issues.
- Bright Futures Tool and Resource Kit: Includes pre-visit questionnaires and visit-specific supplemental questionnaires designed to capture relevant patient information and clinical data.