October 2016

Building on the Foundation: From Patient History to Physical Exam

Last month, medical history was reviewed as the foundation of an examination, but the physical exam serves as another important component for Texas Health Steps (THSteps) and well-child exams. According to the Texas Health and Human Services Commission (HHSC), an unclothed physical exam is required during all THSteps and well-child checkups. A comprehensive unclothed physical examination includes all the components listed below:

Measurements

• Requires documentation of measurements and percentiles as appropriate:

• Length or height and weight;
• Fronto-occipital circumference – birth through 24 months of age;
• Body Mass Index (BMI) – Beginning at 2 years of age; and,
• Blood pressure – Beginning at 3 years of age.

• Texas Health Steps recommends that health care providers:

• Use the World Health Organization (WHO) growth charts for infants and children birth to 2 years of age.
• Use the Centers for Disease Control and Prevention (CDC) growth charts for children who are 2 years of age or older.
  

Sensory Screening

• Vision Services – Requires subjective and acuity screening at various ages; see THSteps Periodicity Schedule for details.
• Hearing Services – Requires subjective and audiometric screening at various ages; see THSteps Periodicity Schedule for details.

Vision and hearing screenings are not covered when completed to meet day care, Head Start or school program requirements unless completed during an acute-care visit in a clinic setting.

Documentation of test results from a school vision or hearing screening program may replace the required screening if conducted within 12 months of the checkup. A vision and hearing screening must be completed according to the requirements of the THSteps Periodicity Schedule.

Source: Comprehensive Unclothed Physical Examination, June 27, 2016. Texas Health Steps Checkup Components