HealthCheck Training
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e-mail us at healthcheck@ncemch.org
Post-Test
Overview
Health Supervision
- Introduction
- Health History
- Physical Examination
- Screening Services
- Laboratory Tests
- Immunizations
- Health Education
Special Health Issues
- Introduction
- Dental Health
- Overweight and Obesity
- HIV Guidelines
- Child Abuse & Neglect
- Language Barriers
- Early Intervention
Documentation
Go To Resources »
Documentation
Documentation
of all components of the health visit is required on
each child's medical record. The medical record chronologically
documents the
care of the child and is an important element in contributing
to high quality health care.
Carefully documenting each visit helps to:
- Identify gaps in preventive care.
- Enhance both quality and continuity of care.
- Identify health or developmental concerns and intervene early.
- Avoid duplicative screenings and tests (when previous results not documented).
- Ensure compliance with HealthCheck/EPSDT mandates.
- Facilitate external chart review.
- Improve data collection and evaluation.
- Maximize reimbursement.
Provider Tip: Legible DocumentationAvoid medical mistakes and ensure that services are counted; write legibly. Document what you do and make sure that anyone and everyone can read it. Remember: "If it can't be read, it didn't happen!" |
