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43.2.1 Documentation of Completed Check Ups
To assure completion of comprehensive medical check ups and the quality of care provided, providers must document all components of the THSteps medical check ups as they are completed. Clinical charts are subject to quality review activities including random chart review and focused studies of well-child care.
In acknowledgment of the practical situations that occur in the office or clinic settings, the AAP has stressed the philosophy that the components of all medical check ups should be performed when appropriate to the needs of the individual client. Consequently, completion of all recommended components of a THSteps medical check up may require follow-up check ups.
The Centers for Medicare & Medicaid Services (CMS) has clarified, in its Medicaid Guide To State Entities, the following expectations for the content of comprehensive preventive health visits:
• Comprehensive health history, including developmental and nutritional assessment.
•Comprehensive unclothed physical examination, including graphic recording of head circumference.
•Appropriate immunizations as indicated in the Recommended Childhood and Adolescent Immunization Schedule.
•Age-appropriate laboratory tests for anemia, lead poisoning, and newborn screening.
•Health education, including anticipatory guidance, is required.
•Age-appropriate vision and hearing screening.
•Direct referral to dental check ups beginning at 12 months of age.
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