Child Health Clinical Record Form Instructions

Texas Health Steps (THSteps) checkup forms serve as a complete documentation tool for each specific age (excluding the newborn examination) on the THSteps Periodicity Schedule. The use of these forms is not mandatory for THSteps providers, but the forms will assist the providers in assuring documentation of all required components of a THSteps medical checkup.

The front side of each form includes areas of documentation for the federally mandated components of the checkup, including “History,” “Immunizations,” “Laboratory,” “Unclothed Physical Examination,” and “Health Education Including Anticipatory Guidance.” There is also space available for “Assessment” of the current checkup and any follow-up planning and/or recommended referrals to other providers. Beginning at 6 months of age, the form also includes space for the required dental referral.

These instructions are organized by each mandated component. Not all items on the forms are included in these instructions, as some items are self-explanatory. Items that are not required for a specific age checkup are not included on the form for that age.

A notation should be made in each area using the check boxes or lines provided and space, if needed, to elaborate on findings. If using the forms in an electronic format, the spaces are able to be edited and may have a blue shading that shows over some sections. If that happens and is not wanted, click on the “Highlight Existing Fields” box in the upper right-hand corner, and the blue shading will disappear but the editing feature will remain. The tab feature will move the cursor through the form. If notations are not made on the form, supplemental documentation must be maintained in the medical record. The provider may write “N/A” if not applicable, use the symbol “Ø” for “None noted,” or write “None.” In areas with a Y (Yes) or N (No) or a P (Pass) or F (Fail) check box, check one of the boxes and notate findings, if appropriate, in the space provided. If there is a box for a section heading, check the box if any item(s) was/were addressed.

DEMOGRAPHICS

Complete the patient demographic section for each periodic checkup:

  • NAME: = the patient’s name
  • DOB: = the patient’s date of birth
  • GENDER: = the gender of the patient
  • DATE OF SERVICE: = the date of the checkup
  • MEDICAID ID: = the patient's Medicaid ID number
  • PRIMARY CARE GIVER: = name of the person whom the patient lives with and who provides care of the patient
  • PHONE: = telephone number where the Primary Care Giver may be reached for contact
  • INFORMANT: = the name of the person accompanying the patient and who is giving and receiving the information needed on the patient’s history and the Health Education and Anticipatory Guidance
Demographics
NAME: MEDICAID ID:
DOB: PRIMARY CARE GIVER:                                
GENDER:         MALE       FEMALE           PHONE:
DATE OF SERVICE: INFORMANT:

HISTORY

A comprehensive health and developmental history is a federally mandated component of the medical checkup and must be completed at every checkup. A comprehensive new patient personal and family history form of the provider’s choosing is completed at the initial checkup as a separate form. It must be retained in the medical record for reference at future checkups. For the initial checkup, this box may be checked without the need for further completion of the interval history section. The box is checked at all subsequent checkups to indicate there is a comprehensive new patient personal and family health history completed and in the record.

See new patient history form
 See new patient history form

If the initial comprehensive personal and family health history was completed previously and is in the record, it is not required to be completed at subsequent checkups.

INTERVAL HISTORY

This section is completed as an interim history to supplement the initial history and includes documentation of mental  health, developmental, nutritional, and tuberculosis screening. It also includes items that may have changed since the comprehensive personal and family health history was recorded or may include additional information that would impact the current checkup.

Interval History
Visits to other health-care providers, facilities: 

List all known visits to hospitals, other providers such as specialists, primary care physician (PCP) if this checkup is not performed by the PCP, or facilities, such as radiology or other outpatient facilities.

Mental health
Psychosocial/Behavioral Health Issues, including Post-
partum Depression Screening (use of validated tool
required):  EPDS PPDS PHQ-9 Other P F
Findings:

Mental health screening of the patient is required at each checkup birth through 20 years of age. Screening for postpartum depression is recommended but not required. Texas Health Steps recommends the screening be completed within the first few months following birth and up to the infant’s first birthday. A validated screening tool must be used. Check the box in front of the tool used and indicate “Pass” or “Fail.”

Developmental/mental health
DEVELOPMENTAL/MENTAL HEALTH SCREENING:
(use of validated tool required): PSC-17 PSC-35
Y-PSC PHQ-9 PHQ-9 CRAFFT PHQ-A (AAP tool:
anxiety, eating disorders, etc.) PHQ-A (depression
screening) P F Findings:

Mental health screening is recommended annually for adolescents 12 through 18 years of age. A Texas Health Steps approved validated and standardized mental health screening tool is required. Check the box in front of the tool used and indicate “Pass/Fail.”

Lead risk assessment should be done beginning at six months through six years through anticipatory guidance. The back of the form contains questions related to lead risk factors and information about Form Pb-110, Lead Risk Questionnaire. The form is available at http://www.dshs.texas.gov/thsteps/forms.shtm and may be completed for reporting purposes and faxed or mailed as noted on the bottom of the form to the Department of State health Services (DSHS) Lead Program for every child screened, whether or not the results show a risk of lead exposure. Blood lead screening is required at 12 and 24 months.

TB
TB questionnaire*, risk identified:  Y   N 
*Tuberculin Skin Test if indicated  TST 
(See back for form)  

Screening for tuberculosis (TB) is a required part of the history at certain ages. The questions contained in the THSteps TB questionnaire are located on the back of the checkup forms  for specific ages and can serve as documentation for TB screening.

Developmental screening

DEVELOPMENTAL SCREENING:
Use of standardized tool: P  F  
ASQ PEDS    
Autism screening: P  F 
M-CHAT™  M-CHAT-R/F™  

Development surveillance/screening through 6 years of age is required as part of the history, with use of a validated and standardized developmental screening tool at specific ages. Check the box in front of the tool used, and indicate "Pass/Fail".

OR

Developmental Surveillance
 DEVELOPMENTAL SURVEILLANCE:
• Gross and fine motor development
• Communication skills/language development
• Self-help/care skills
• Social, emotional development
• Cognitive development
• Mental health

At ages that do not require a standardized screening tool, the checkup must include a review of milestones as listed on the form. Check the box in front of “Developmental Surveillance” to document review of milestones. Document abnormal findings and action taken for both the standardized screenings and the review of milestones in the space provided or on additional paper as needed. Referral for further assessment can be documented in the “Plan/Referrals” section.

Nutrition

NUTRITION*:
Breastmilk
Min per feeding:____              Number of feedings in last 24 hrs:____
Formula (type)_______________________________________
Oz per feeding:____       Number of feedings in last 24 hrs:____
Water source:_______________                   fluoride: Y  N           

Solids_____________________________________________

*See Bright Futures Nutrition Book if needed 

OR

Nutrition 2
NUTRITION*:
Problems:     Y      N 
Assessment:

*See Bright Futures Nutrition Book if needed    

Nutrition screening is a required part of the history. For younger ages, notate the type of nutrition and the amount received as appropriate. For ages without an age-specific nutrition review, check the Y or N box as assessed and notate any appropriate findings in the “Assessment” space in this section. If needed for completion of this item, refer to Bright Futures at  http://brightfutures.aap.org/Nutrition_3rd_Edition.html as indicated by the asterisk.

IMMUNIZATIONS

Age-appropriate screening and administration of immunizations according to the schedule established by the Advisory Committee on Immunization Practices (ACIP) is a federally mandated component of the checkup. The form allows space for documenting up-to-date or deferred immunizations, including rationale for deferral. Each form also includes the age-appropriate vaccine choices. Check the box for any vaccines given the day of the checkup. The separate immunization record also serves as sufficient documentation.

LABORATORY

Laboratory services with screening for age-appropriate laboratory tests are a federally required component of the checkup. This section includes age-appropriate required laboratory tests. Check the box(s) in front of the lab test to indicate the test(s) ordered. The form allows space for documenting additional tests that are ordered. Separate forms indicating laboratory tests ordered/results also serve as sufficient documentation.

Signature
___________________________________
Signature/Title 

The person completing the checkup and the staff assisting in completion of the checkup sign on the line with their title included.

UNCLOTHED PHYSICAL EXAM

A comprehensive unclothed physical examination including a graphic recording over time of measurements for comparison to national norms for the patient’s age is a federally required component of the checkup.

growth graph
See growth graph          

Check the box to indicate the growth graph has been completed and measurements are notated on the graph retained in the record. Resources for growth may be found at http://www.dshs.texas.gov/thsteps/forms.shtm. The measurement area provided for notating during the visit is then optional for use.

measurements
Weight:____ (____%) Length:____ (____%)
BMI:____ (____%) Head Circumference:____ (____%)

The form allows space for documenting the physical examination and findings.

WNL
Normal (Mark here if all items are WNL) 

Check the box if all items in the table are within normal limits (WNL).

ABNORMAL
Abnormal (Mark all that apply and describe): 

Check only the box adjacent to the body part with the abnormal result.

AF
Appearance       Nose Lungs
Head Mouth/throat         GI/abdomen
Skin Teeth Extremities
Eyes Neck Back
Ears Heart Musculoskeletal    
    Neurological
Abnormal findings: _______________  

Document all abnormal findings in the space below the table or on additional paper as needed.

additional

Additional: 

                                                     

The form contains space for additional documentation.

tanner scale
Breasts____/5 Genitalia____/5     

Document the tanner stages on the lines provided.

NBS

Newborn Hearing Screening:
Completion date:___/___/___ Results:

Critical Congenital Heart Disease Screening:
Completion date:___/___/___ Results:         

Document the results and completion date of the newborn hearing test in this section. Results may be accessed at https://www.provideraccess.tehdi.com using a current user name and password. If no user name or password has yet been established, contact TEHDI at call 512-776-7726 or 512-776-2128, or contact OZ Systems at 866-427-5768 option 2 or email: OzHelp@oz-systems.com to obtain the required login information. Document the completion date and results of the newborn critical congenital heart disease testing completed in the birthing facility in this section.

Standardized sensory screenings for vision and hearing are required as part of the physical examination, including visual acuity and audiometric screening tests at specific ages. Visual acuity and audiometric screening tests performed during the checkup may be documented on the lines provided or maintained as supplemental documentation in the medical record.

Documentation of test results received from a school vision and hearing program or other source may replace the required visual acuity or audiometric screening if conducted within the 12 months prior to the checkup. If testing was completed elsewhere, documentation of the results including the date and the name of the provider who completed the screening must be retained in the medical record.

The actual results must be maintained in the record.

SHS SVS
Subjective Hearing Screening:   P   F
Subjective Vision Screening:     P   F      

The Hearing Checklist for Parents is available on the back of the checkup form for reference for specific ages as an optional tool. Subjective sensory screenings through provider observation and/or informant report are documented by checking the appropriate box when a visual acuity or audiometric screening test is not required.

HEALTH EDUCATION / ANTICIPATORY GUIDANCE (See back for useful topics)

Health Education Including Anticipatory Guidance is a federally required component of the checkup.

health topics
Selected health topics addressed in any of the
following areas*:
• School Readiness/Limitations • Nutrition
• Personal Hygiene • Safety 

General categories for useful health education topics are listed in this section, and specific age-appropriate topics are listed on the back of the form. Checking the box indicates that health education and anticipatory guidance were provided as required. there is no requirement to document specific subject(s) covered, although the provider may choose to do so separately from the form. If there is a problem requiring an action or outcome, documentation may be made in the space provided for “Assessment” and “Plan/Referrals.”

ASSESSMENT

PLAN / REFERRALS  

dental referral
Dental Referral:   Y   

Beginning at 6 months of age, a dental referral is a required component of the checkup until a dental home is established and may be documented here or with supplemental information maintained in the medical record.            

return

Return to office:                                        

The time that is recommended for a return appointment may be documented in this section. It does not have to include the exact date but may include a time frame for the return checkup or follow-up visit.

sign 2
 ___________________________________
Signature/Title

The person completing the checkup and the staff assisting in completion of the checkup sign on the line with their title included.


BACK OF FORMS

The back of each form includes age-appropriate Health Education and Anticipatory Guidance, and modified versions of screening questionnaires.

Typical Developmentally Appropriate Health Education Topics        

The health topics included in the list for each age group are age-specific. No notation is required on the back of the form; only the check in the box on the front of the form is required.

Reference materials may be found at http://brightfutures.aap.org/

HEARING CHECKLIST FOR PARENTS (OPTIONAL)               

TB QUESTIONNAIRE     

LEAD RISK FACTORS


Print version-Child Health Record Form Instructions [PDF 300KB]

 

 

 

Last updated July 2, 2018