EMRs & Required Data

Specific information must be documented for a well-child visit to count as a reimbursable HealthCheck visit. With the rapid adoption of Electronic Medical Records (EMRs) in DC's pediatric community, the challenge is to ensure that the required information needed for a complete HealthCheck visit is captured electronically.

Click on the letters below to see the specific data points necessary in recording HealthCheck visits in EMRs. Note specific documentation hints in [brackets].

EPSDT

Early

For all HealthCheck visits, be sure to indicate whether first or periodic visit and list drug allergies.

  • Record the following, remembering that complete documentation is a goal:
Patient name
Date of birth
Gender
Age
Date/time of visit
Insurance ID number
Who accompanied patient
Contact phone numbers
Weight
Height
Head Circumference (up to 2 years)
Blood pressure (3-21 years)
  • While not required by HealthCheck, you may want to record details of the following:
Interpreter used? [yes/no/primary language] Pain? [yes/no/score/management plan]

Periodic

The DC Medicaid HealthCheck Periodicity Schedule follows the American Academy of Pediatrics (AAP) health recommendations in consultation with the local medical community. The recommendations are for the care of children who have no manifestation of any important health problems. Additional visits or interperiodic screens may become necessary if circumstances suggest the need for more screens, i.e., medical conditions, referral by parent, Head Start, DC Public Schools, Early Intervention Programs. If a child comes under care for the first time at any point on the schedule, or if any items are not done at the suggested age, the schedule should then be brought up to date as soon as possible.

Screening Services

A HealthCheck visit must include ALL of the following (click to see details):

Comprehensive Health and Developmental History
  • History/Parent Concerns:
    • Newborn: Record a birth history; issues/complications during pregnancy (list medications, illnesses, drugs, ETOH); gestational age; birth weight; APGARS; complete a newborn history by 9 months.
    • All visits: Interval history completed? [yes/no; record comments]; list current medications.
  • Social/Family History:
    • For all visits: review social/family history with patient/guardian (or with teen for adolescent visits) and document. Completed? [yes/no; record notes].
    • Items of note: Record child care [yes/no/type] for 0-5 years; record preschool [yes/no] for 2-5 years. For 6-21 years, record comments on: home; education; emotional/behavior; exercise; activities/friends; diet/eating behavior; drug/alcohol/tobacco; sleep; sexual awareness/activity; abuse/violence; menarche; LMP.
    • Dental visit in last 12 months? [yes/no/record answer] (dental referral required yearly 3-21 years and at earlier ages if necessary).
  • For more information, see the Health History module in the HealthCheck Extended Training.
Comprehensive Unclothed Physical Exam
  • 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].
  • For more information, see the Physical Exam module in the HealthCheck Extended Training.
Screening Services and Assessments
  • Nutrition Assessment:
    • Record accurate measurements of the child's height and weight—these are among the most important indices of nutritional status. For 0-18 months: Breastfed or formula fed? [record formula type].
    • Ask the family about dietary practices to identify unusual eating habits or diets that are deficient in nutrients and calories, or excessive in cholesterol and fat.
  • Vision Screening:
    • Required at 3,5,6,8,10,12,15,18 years according to the DC Medicaid HealthCheck Periodicity Schedule.
    • Document visual acuity (for both left eye and right eye); [score 20/__] and indicate [corrected or uncorrected]; document if an unsuccessful attempt.
  • Hearing Screening:
    • Newborn hearing screening required.
    • Additional screenings required at 5,6,8,10,12,15,18 years according to the DC Medicaid HealthCheck Periodicity Schedule.
    • Document [passed or failed]; document if an unsuccessful attempt.
  • Developmental Screening:
    • Required at all visits according to the DC Medicaid HealthCheck Periodicity Schedule.
    • Development: indicate tool used (Denver Developmental II or other): see areas of development (PDF) to be recorded.
    • Speech and language: evaluate the infant’s or child’s communication abilities in comprehension, expressive language, speech development, and social language.
  • Dental Evaluation:
    • Dental evaluation follows the DC Medicaid HealthCheck Dental Periodicity Schedule (PDF).
    • Oral screening must be part of every well-child physical exam, but should not be seen as a substitute for an exam by a dentist.
    • An oral assessment should be done by the primary care physician/pediatrician up to age 3. Every Medicaid-enrolled infant should receive an oral health risk assessment from his/her primary health care provider or qualified health care professional by 6 months of age that includes: (1) assessing the patient’s risk of developing oral disease using the AAPD Caries-risk assessment tool; (2) providing education on infant oral health; and (3) evaluating and optimizing fluoride exposure.
    • All Medicaid-enrolled children should be referred to a dentist for the establishment of a dental home within 6 months after the first tooth erupts, or 12 months of age (whichever comes first). Providers should encourage families to take their child to a dentist every 6 months.
    • The oral assessment done by the primary care physician/pediatrician should not be in place to a visit to a dentist, and should include the importance of oral care and a referral to a dentist.
    • For assistance in finding a dentist and scheduling an appointment, caregivers should be encouraged to call the Dental Helpline: 866-758-6807.
  • For more information, see the Screening Services module in the HealthCheck Extended Training.
Laboratory Tests
  • Metabolic and Hemoglobinopathy:
    • For 0-4 months: record newborn metabolic tests [pending/normal/abnormal; list comment if abnormal].
    • Tests should include sickle cell, G-6-PD deficiency, congenital hypothyroidism, galactosemia, phenylketonuria, maple syrup urine disease, and homocystinuria.
  • Lead:
    All children covered under Medicaid should receive 2 blood lead tests.
    • District law requires all Medicaid-enrolled children receive a lead test at least twice: first between ages 6 and 14 months, and a second time between ages 22 and 26 months.
    • In addition, if there is no documentation of previous lead screening, federal law requires that all Medicaid-eligible children between the ages of 36 and 72 months of age also receive a screening blood lead test.
    • All other children 36-72 months require a test unless assessed as low lead risk. Lead level of concern: greater than or equal to 5 ug/dL.
    • For more information, contact the DC Lead Poisoning Prevention Division at (202) 535-2634 or 535-1394.
    • See screening guidelines, verbal risk assessment, and DC lead resources in the Lead Section of the HealthCheck Extended Training.
  • Anemia (Hemocrit or Hemoglobin):
    • Infancy: all infants at 9 and 12 months (or earlier if high risk). Screen again at 15, 18, and 24 months if high risk.
    • For 3-10 years: screen at each visit.
    • 11-21 years: screen once between 11 and 20 years; screen menstruating females annually.
    • Document: risk [low/high]; if previously done: [normal/abnormal]; or if ordered.
  • Cholesterol/Dyslipidemia:
    • From 3-21 years: Review and document risk factors [low/high].
    • If at high risk: screen with lipid profile blood test.
    • Note: AAP recommends lipid profile at ages 6, 8, 10, and annually if at high risk.
  • Tuberculosis:
    • Infancy and early childhood: perform Mantoux skin test (PPD) at 12 months; once between 3-5 years (all children entering school must have a PPD test).
    • Early childhood: test once 3-5 years; if at high risk: test between 15-24 months.
    • For 8-21: test annually.
    • Document: TB risk: [low/high]; if high: [PPD ordered].
  • STIs and Pregnancy:
    • Infancy: screen all infants born to infected mothers.
    • Adolescents: screen all sexually active teens starting at 11 years for STIs; offer pregnancy testing routinely to all sexually active females. Perform a pelvic examination and Pap smear should be performed on all sexually active females and females between 18-21 years.
    • Document: STI risk: [low/high]; if high: [screens ordered].
  • For more information, see the Laboratory Tests module in the HealthCheck Extended Training.
Immunizations
  • Administer and document immunizations according to the current ACIP approved schedule. Record that immunizations have been reviewed, ordered, and/or administered (include date).
  • Record if there are medical/religious exemptions and explain.
  • Record any general comments.
  • For more information, see the Immunizations module in the HealthCheck Extended Training.
Health Education
  • Health education, including anticipatory guidance, is a required EPSDT component to be presented and documented at each preventive health visit.
  • Broad categories for anticipatory guidance include: sleep positioning (0-6 months), injury prevention, violence prevention, and nutrition counseling.
  • See Suggested Age Appropriate Topics for Anticipatory Guidance (PDFs):
    0-1 month | 2-4 months | 6-9 months | 12-18 months | 2-5 years | 6-10 years | 11-21 years.
  • Document: record that anticipatory guidance was provided and that educational handouts and/or plan was reviewed with patient/parent. Ensure that patient/parent verbalizes understanding.
  • For more information, see the Health Education module in the HealthCheck Extended Training.
Interperiodic Screens
  • In addition to covering scheduled, periodic check-ups, HealthCheck/EPSDT covers visits (interperiodic screens) to a health care provider when needed outside of the periodicity schedule to determine whether a child has a condition that needs further care.

Diagnosic

  • If screenings indicate need for further evaluation, diagnostic services must be provided. Referrals should be made without delay, including follow-up to ensure that a diagnostic evaluation is received.
  • If you have difficulty finding information on where to refer, call the Office of the Ombudsman 877-685-6391.
  • Assessment and Plan: record your assessment based on the visit and plan for further diagnostics. Document concerns, including the following:
Hearing concern
Prematurity
Developmental delay
Behavior/MH concern
Special health needs
Asthma
Wheezing/RAD
Dental
Obesity
Learning disorder(s)
Epilepsy/Seizure(s)
  • Document: record the type of referral made and the date of the next follow-up visit. Also record that this was a Well Child visit.
  • All Medicaid-enrolled children should be referred to a dentist for the establishment of a dental home within 6 months after the first tooth erupts, or 12 months of age (whichever comes first). See Dental Evaluation under Screening Services (above) for more information.
  • Dental Helpline: 866-758-6807.

Treatment

  • All Medicaid-enrolled children should receive comprehensive EPSDT treatment services, including: developmental services, eyeglasses, hearing aids, orthodontia, wheelchairs and prosthetic devices, occupational and physical therapy, prescribed medical formula and nutritional supplements, assistive communication devices, personal care, therapeutic behavioral services (TBS), behavioral rehabilitation, home health, speech therapy, and substance abuse treatment. For for the full scope of services covered under HealthCheck, see Medicaid's EPSDT Scope of Benefits (PDF).
  • For more information, see Johnson, K. 2010. Managing the "T" in EPSDT Services. Washington, DC: National Academy for State Health Policy.

Summary

If a health care provider determines that a service is needed, it should be covered to the extent needed and allowed under the federal Medicaid Act. For example, if a child needs personal care services to ameliorate a behavioral health problem, then HealthCheck/EPSDT should cover those services to the extent the child needs them — even if the state places a quantitative limit on personal care services or does not cover them at all for adults.

Resource for Providers: Electronic Medical Records

The American Academy of Pediatrics' Council on Clinical Information Technology (COCIT) hosts an online EMR Review Project featuring members' experiences with various EMR systems. Visit http://www.aapcocit.org/emr/index.php.

The American Academy of Family Physicians' Center for Health Information Technology also provides online guidance about EMRs and hosts an EMR e-mail discussion list. Visit http://www.centerforhit.org.

HRSA's Health IT for Children Toolbox is a compilation of health IT information targeted at children's health care needs, ranging from pediatric electronic medical records to children's health insurance coverage. It also discusses opportunities to link other systems that serve children, including Head Start, schools, and foster care.

For an overview of the issues, visit http://www.openclinical.org/emr.html.

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Information from this page is summarized from the following:

DC Department of Health Care Finance. HealthCheck Periodicity Schedule.

Clark EM, Anastasi JM, Richards JT. 2008. Well-Child Care: A Bright Futures Pocket Guide for Pediatric Providers. Washington, DC: Georgetown University.

Johnson, K. 2010. Managing the "T" in EPSDT Services. Washington, DC: National Academy for State Health Policy.

Perkins, J. 2008. Medicaid Early and Periodic Screening, Diagnosis and Treatment Factsheet. Washington, DC: National Health Law Program.