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5.4.1 THSteps Medical Checkups-Documentation of Completed Checkups
To assure completion of comprehensive medical checkups and the quality of care provided, providers must document all components of the THSteps medical checkups as they are completed. Clinical charts are subject to quality review activities including random chart review and focused studies of well-child care. Documentation must support services provided according to nationally recommended standards of care.
The required components of the medical checkup must be documented in the client's medical records. If the component cannot be completed due to extenuating circumstances, such as the client's illness or lack of cooperation or the parent's refusal to give consent for a specific component, the provider must document in the client's medical record why the component was not completed and must schedule a follow-up visit as appropriate. A checkup is considered complete if the provider has attempted to complete all required components and documentation supports the reason why the required component could not be completed.
Documentation for a follow-up visit must include:
• Reason for the visit(s)
•Component(s) completed
Documentation of the questions contained in the following screening tools are required for THSteps risk identification:
•Hearing Checklist for Parents
•Tuberculosis (TB) Screening and Education Tool
•Form Pb-110, Risk Assessment for Lead Exposure: Parent Questionnaire
Documentation of these screening tools must be included in the client's medical record as follows:
•If another program requires the screening tool to be submitted, it must be completed and included in the client's medical record.
•If another program does not require the screening tool to be submitted, it must have one of the following forms of documentation included in the client's medical record:
•The completed screening tool(s) with results
•The completed questions to the tool(s) within a provider-created medical record
•The results of the completed screening tool(s)
•Providers may be asked to provide the screening tool used to complete the screening.
All other THSteps forms are optional.
Any component of the checkup obtained within the preceding month may be used to meet the checkup requirement and must include:
•The date(s) of service
•Clear reference to the previous visit by the same provider or results obtained from another provider
In addition to the required documentation for a checkup, the client's medical record must include the reason for the exception-to-periodicity checkup.
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