January 2018
Texas Health Steps Procedures and Documentation Reminder
As a Texas Health Steps (THSteps) provider, you are aware of the importance of providing timely immunizations and complete laboratory tests for your patients at the time of their checkup. It is also important to have these services completed at the appropriate checkup according to the THSteps periodicity schedule.
Remember to properly document each service in the medical record. Documentation must include any component or element of the checkup that was not completed, the reason it was not completed and the plan to complete it. Additionally, any screening tools that were utilized during the checkup must be included in the medical record documentation. A complete list of age-specific components can be found on the THSteps Periodicity Schedule. Details of each component are listed in the Children’s Services handbook of the Texas Medicaid Provider Procedures Manual.
As a reminder, the six THSteps checkup components include:
- Comprehensive health and developmental history, which includes nutrition screening, developmental and mental health screening, and TB screening
- Comprehensive unclothed physical examination, which includes measurements of height or length, weight, fronto-occipital circumference, BMI, blood pressure, and vision and hearing screening
- Immunizations, as established by the Advisory Committee on Immunization Practices, according to age and health history, including influenza, pneumococcal and HPV
- Laboratory tests, as appropriate, which include newborn screening, blood lead level, assessment appropriate for age and risk factors, and anemia
- Health education, including anticipatory guidance
- Dental referral, starting at 6 months of age and at every checkup thereafter until the parent or caregiver reports a dental home is established