Health Supervision
Physical
Examination: Introduction
 A
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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