comprehensive unclothed physical examination is an essential
part of each preventive health visit and is a required EPSDT
examinations should be performed according to the DC Medicaid HealthCheck
the exam, infants should be totally unclothed and older
children should be undressed and suitably draped in a
consists of a systematic inspection of all parts of the
body. The general appearance of the child should also be
noted to determine overall health status.
the Physical Examination
- For all visits: indicate unclothed exam. Document [normal/abnormal] and record comments:
general appearance; head/neck/fontanelle (in infants); eyes (Red Reflex from 1 week-2 1/2 years); ears/nose/mouth/throat; chest/lungs; heart/pulses; abdomen; genitalia/rectum; extremities/hips; back; skin/hair; neurologic.
- For 0-5 years: Assess nutrition, elimination, environment, and sleep patterns [yes/no; record notes]. Assess development assessed [yes/no; indicate tool used -- Denver Developmental II or other]. See areas of development (PDF) to be recorded.
- For 6 months-21 years: include dental (dental referral required yearly 3-21 years and at earlier ages if necessary).
- For 2-21 years: Dental visit in last 12 months? [yes/no].
- For 7-21 years: include neck/nodes; breasts: SMR (Tanner): [1-5]; genitalia (pelvic as indicated): SMR (Tanner): [1-5].
- Remember to consult and follow the DC Medicaid HealthCheck Preiodicity Schedules (health and dental).