From the Guidelines
A health maintenance visit should include a comprehensive assessment of overall health status, including disease detection and prevention, health promotion, and anticipatory guidance, as recommended by the most recent and highest quality study 1. This assessment typically involves reviewing medical history, family history, and current medications, as well as performing a physical examination to check vital signs like blood pressure, heart rate, respiratory rate, and temperature. The visit often includes preventive screenings appropriate for the patient's age, sex, and risk factors, such as:
- Blood tests for cholesterol and glucose levels
- Cancer screenings (like mammograms, colonoscopies, or Pap smears)
- Immunization updates Additionally, the healthcare provider will assess mental health, discuss lifestyle factors including:
- Diet
- Exercise
- Sleep habits
- Substance use and provide counseling on risk reduction strategies, as outlined in the study 1. For patients with established diabetes, the visit should include an interval medical history, assessment of medication-taking behavior and intolerance/side effects, physical examination, laboratory evaluation, and assessment of risk for complications, diabetes self-management behaviors, nutrition, psychosocial health, and the need for referrals, immunizations, or other routine health maintenance screening, as recommended by 1. It is also important to develop a plan for continuing care and to guide ongoing management with the assessment of diabetes complications and shared decision making to set therapeutic goals, as suggested by 1. Overall, the goal of a health maintenance visit is to provide a comprehensive approach to health care, allowing for early detection of potential health issues and helping to establish personalized preventive care plans to maintain optimal health over time, as supported by the evidence from 1 and 1.
From the Research
Components of a Health Maintenance Visit
A health maintenance (HM) visit typically includes several key components, such as:
- Patient history: addressing patient and parent/caregiver concerns, lifestyle habits (diet, physical activity, daily screen time, secondhand smoke exposure, hours of sleep per night, dental care, safety habits), and school performance 2, 3, 4
- Physical examination: a full physical examination to detect signs of abuse, and screen for obesity, hypertension, vision and hearing problems, and dyslipidemia 2, 3, 4
- Screening: screening for various health conditions, such as depression, intimate partner violence, and substance misuse 2, 5, 3
- Immunizations: age-appropriate immunizations and catch-up immunizations 2, 3, 4
- Counseling: counseling to prevent injury and future health problems, such as counseling on reducing the risk of sexually transmitted infections, and promoting healthy lifestyle habits 2, 5, 3
Specific Screening Recommendations
Specific screening recommendations vary by age and population, but may include:
- Screening for obesity and elevated blood pressure in adults 5
- Screening for dyslipidemia in women 20 years and older who are at increased risk of coronary heart disease 5
- Screening for type 2 diabetes mellitus in adults with sustained blood pressure greater than 135/80 mm Hg 5
- Screening for cervical cancer, breast cancer, and colorectal cancer in women, according to recommended guidelines 5
- Screening for osteoporosis in women 65 years and older, and in younger women with a similar risk of fracture 5
Importance of History Taking
History taking is a crucial component of a health maintenance visit, as it allows healthcare providers to gather relevant information from patients and inform diagnosis and treatment 6. Effective history taking involves active listening, empathetic communication, and cultural sensitivity, and can help facilitate patient participation and autonomy 6.