Instructions for "Epsdt Screening Form Guidelines" - Nevada

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EPSDT Screening Form Guidelines
1. Patient’s Medical History
• New patient - Fill in all blanks with birth weight, birth height, etc.
• Established patient - Check if history from previous visit was reviewed and note if
there are any changes.
2. Family Medical History
• New patient – Check disease and indicate family member, i.e. parent,
grandparent, brother or sister.
• Established patient – Check if completed family history is already part of the
chart or if any updates.
3. Growth/Vital Signs
• Fill in all blanks with current height, weight, vital signs, etc.
-
If patient is < 1 year, measure head circumference (HC)
-
If patient is > 1 year, calculate Body Mass Index (BMI), if indicated.
-
Nutrition – for infants, indicate if bottle-fed, breast-fed, on solids, etc.
for children, indicate if nutrition is poor, fair, good or excellent
4. Physical Exam – unclothed
• Fill in each area with either an “N” – normal, “A” – abnormal, or “NE”- no exam.
• Describe any abnormalities.
5. Developmental/Emotional Behavior
• Check “yes” or “no” if development is age/culturally appropriate. If not,
elaborate.
• If a developmental or emotional screening tool was used, indicate the name of the
tool, i.e. “Ages and Stages”, “Denver Developmental II”, “Pediatric System
Checklist – PSC”.
• If a referral was made for developmental/emotional problems, indicate the
specialist.
6. Anticipatory Guidance/Nutrition/Safety
• Check-mark each area that was discussed with the parent and/or child.
EPSDT Screening Form Guidelines
1. Patient’s Medical History
• New patient - Fill in all blanks with birth weight, birth height, etc.
• Established patient - Check if history from previous visit was reviewed and note if
there are any changes.
2. Family Medical History
• New patient – Check disease and indicate family member, i.e. parent,
grandparent, brother or sister.
• Established patient – Check if completed family history is already part of the
chart or if any updates.
3. Growth/Vital Signs
• Fill in all blanks with current height, weight, vital signs, etc.
-
If patient is < 1 year, measure head circumference (HC)
-
If patient is > 1 year, calculate Body Mass Index (BMI), if indicated.
-
Nutrition – for infants, indicate if bottle-fed, breast-fed, on solids, etc.
for children, indicate if nutrition is poor, fair, good or excellent
4. Physical Exam – unclothed
• Fill in each area with either an “N” – normal, “A” – abnormal, or “NE”- no exam.
• Describe any abnormalities.
5. Developmental/Emotional Behavior
• Check “yes” or “no” if development is age/culturally appropriate. If not,
elaborate.
• If a developmental or emotional screening tool was used, indicate the name of the
tool, i.e. “Ages and Stages”, “Denver Developmental II”, “Pediatric System
Checklist – PSC”.
• If a referral was made for developmental/emotional problems, indicate the
specialist.
6. Anticipatory Guidance/Nutrition/Safety
• Check-mark each area that was discussed with the parent and/or child.
7. Impression
• Check “yes” or “no” if child is well and if growth & development are normal. If
not, indicate diagnosis.
• Indicate age that next screening is due.
8. Treatment Plan/Referral
• Indicate if fluoride varnish was applied.
• Was child referred to a dentist?
• If child is referred to a specialist, indicate type of specialist.
9. Immunizations Given
• Is child up-to-date on immunizations? If not, indicate which immunizations were
given, whether single or combination.
10. Laboratory Ordered
• Is child up-to-date on lab work? If not, indicate which lab tests were ordered or
performed in the office.
• NOTE: Blood lead levels are required at 12 months and 24 months of age or at
36 months of age if no previous testing has been performed.
March 2008
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