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Provider Manual

HealthCheck Exam Documentation

Last Updated on January 24, 2019

There are several components to a HealthCheck exam.  Each of the following components should be documented in the patient’s medical record when a HealthCheck exam is billed.

HealthCheck checkup includes:

  • Health and developmental history (including anticipatory guidance).
  • Unclothed physical examination.
  • Vision screening
  • Hearing screening
  • Dental screening and a referral to a dentist beginning at age one.
  • Immunizations appropriate for age (shots)
  • Blood and urine lab tests (including blood lead level testing when appropriate for age)

Click here for the ForwardHealth Portal for HealthCheck forms. Scroll down to “HealthCheck” and click on More Information.  Click on HealthCheck Forms and select the age specific form needed.

Health and Development History

Identification of any special risk factors or prior conditions/treatments pertinent to future care of the patient. This history should include:

  • A nutritional assessment: for instance, number of times breastfeeding/day, and fluoride in water
  • Health education/anticipatory guidance: including age-appropriate preventive health education and an explanation of screening findings such as nutrition, safety, normal stages of growth and development.
  • Developmental behavior assessment: observed behavior and developmental milestones compared to age-specific norms.

Unclothed Physical Exam and Growth Assessment

Review of body systems, indicating normal or abnormal findings.

  • Blood pressure: must be taken on all patients beginning at age 3.
  • Growth assessment: height, weight – including weight to length percentile – and head circumference are plotted on growth charts. Head circumference must be completed up to age 2. 
  • Sexual development: especially on patients who have reached puberty. 

Vision Assessment

Use of vision charts must be attempted starting at age 4 and done annually. If attempted but unable to complete due to age, this must be documented. The general guideline is start on the 20/25 line; if unable to read, go up one level. If the child misses one letter on a line, he/she passes. If the child misses two or more in one row, he/she fails. Record vision at the previous level.

If the child wears glasses, vision assessment is not necessary. Document that the child wears glasses, and when he/she was last seen by an optometrist/ophthalmologist for an eye exam. If last optometrist/ ophthalmologist visit is more than one year ago, or if concerns are expressed, reassess vision.

Hearing Assessment

  • Infancy and childhood: This should include otoscopic exam and/or tympanometric measurement for detection of chronic/recurrent otitis media.
  • Puretone audiometric screening must be attempted on all children ages 3 – 8 years, and then every four years to age 16, also, if children are older than 8 years and have excessive exposure to noise, delayed speech/language development, or it is their first HealthCheck. Document if screening is attempted but unable to complete due to age. (General guideline: test at the 20dB level at the following frequencies: 1000, 2000, 4000, 500. If unable to hear at 20dB level, go to the 25dB level.)

If the child wears a hearing aid, a hearing assessment is not necessary. Document that the child wears a hearing aid and when he/she was last seen by an audiologist for an exam. If the last audiologist visit is more than one year ago, or if concerns are expressed, reassess hearing.