Texas Health Steps Checkup Documentation — Essential to Medical Records

As a Texas Health Steps (THSteps) provider you affect the lives of many young Texans. The care you provide helps prevent serious or chronic health-care problems and often helps young patients begin to develop positive lifelong health-care habits. Being a THSteps provider can be very rewarding. It can also be very challenging, especially when it comes to medical checkup documentation. Independent studies of THSteps medical checkups indicate that records were most commonly missing documentation of appropriate laboratory tests and immunizations.

THSteps checkups are made up of six primary components, many including individual components. These are outlined on the Texas Health Steps Periodicity Schedule based on age and include:

1. Comprehensive health and developmental history which includes nutrition screening, developmental and mental health screening and TB screening;
2. Comprehensive unclothed physical examination which includes measurements; height or length, weight, fronto-occipital circumference, BMI, blood pressure, and vision and hearing screening;
3. Appropriate immunizations, as established by the Advisory Committee on Immunization Practices, according to age and health history, including influenza, pneumococcal, and HPV;
4. Appropriate laboratory tests which include newborn screening blood lead level assessment appropriate for age and risk factors, and anemia;
5. Health education (including anticipatory guidance); and
6. Dental referral every 6 months until the parent or caregiver reports a dental home is established.

For you to be reimbursed for THSteps checkups, each of the six components and their individual elements must be completed and documented in the medical record. Any component or element not completed must be noted in the medical record, along with the reason it was not completed and the plan to complete the component or element. The medical record must contain documentation on all screening tools used for TB, growth and development, autism, and mental health screenings. The results of these screenings and any necessary referrals must be documented in the medical record. THSteps checkups are subject to retrospective review and recoupment if the medical record does not include all required documentation.

In support of successful checkup documentation and to assist in documenting each of the components and elements of the checkups, the THSteps program recommends use of the THSteps Child Health Record Forms, which are available for download on the THSteps provider information webpage. Each checkup form is age-specific and can assist you with documenting all required checkup components and elements, including developmental and mental health screenings, laboratory screenings, immunizations, and the dental referral as required until the caregiver reports a dental home is established. The components and elements outlined in the forms can be integrated into electronic health records.

To stay current on THSteps policy and available resources, visit the frequently updated THSteps website for information and policy updates. Information on checkup documentation is also available within THSteps Online Provider Education modules. These modules are free and offer continuing education for healthcare professionals. They are available at www.txhealthsteps.com.

Qualified and caring THSteps providers are vital to keeping young Texans healthy. The preventive health care you provide to young Texans is valued. It is important to reflect this care in the completeness of your medical documentation.