2014 - PCMH3C

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To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes:

  1. Age- and gender appropriate immunizations and screenings.
  2. Family/social//cultural characteristics.
  3. Communication needs.
  4. Medical history of patient and family.
  5. Advance care planning (NA for pediatric practices).
  6. Behaviors affecting health.
  7. Mental health/substance use history of patient and family.
  8. Developmental screening using a standardized tool (NA for practices with no pediatric patients).
  9. Depression screening for adults and adolescents using a standardized tool.
  10. Assessment of health literacy.

For documentation of meeting these factors, PCC recommends that practices complete NCQA's Record Review Workbook. Here is how NCQA describes how to do a record review to meet this element:

Review the patient records selected for the medical record review as required in elements 4B and 4C and document presence or absence of the information in the Record Review Workbook. For each factor to which the practice responds “yes,” it provides one example of how it meets the factor.

Partner and/or PCC EHR practices that use Bright Futures protocols should qualify for all of these. Or if you have defined or customized your own protocols on paper or within PCC EHR, you would just need to document that you address all of these areas.


Examples and screenshots from the EHR or paper chart forms would be required.