HealthCheck Provider Education System

HealthCheck Training

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Overview

Health Supervision

Special Health Issues

Documentation

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Health Supervision

Physical Examination: Introduction

*Physical Exam ImageA comprehensive unclothed physical examination is an essential part of each preventive health visit and is a required EPSDT service.

Physical examinations should be performed according to the DC Medicaid HealthCheck Periodicity Schedule

During the exam, infants should be totally unclothed and older children should be undressed and suitably draped in a light gown.

The examination 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.

 

Documenting 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).

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