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Req-978: Physical exam screening results
Release Package: 2013 Format

Release Package:

2013 Format

Requirement ID:



Physical exam screening results


The system SHALL allow documentation of the presence or absence of age- and gender-specific physical exam findings.

Related Requirements:

Relationship Release Package Requirement ID Requirement Title Requirement Type SHALL / SHOULD / MAY Compare Requirements
Req-978 Is Child Of 2013 Format Req-122 Manage Patient Clinical Measurements Function Not Applicable Compare
Req-978 is associated with 2015 Priority List Req-2020 Physical exam screening results Normative Statement SHALL Compare





Requirement Type:

Normative Statements








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Additional Information:

EPSDT-required periodicity: EPSDT (Early and Periodic Screening, Diagnostic & Treatment Services require periodic screening services (unclothed physical examinations, comprehensive health and developmental history, appropriate immunizations, laboratory tests, and health education including anticipatory guidance as well as vision, dental, hearing, and other necessary health care services ( http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-and-Treatment.html States are required to develop their own EPSDT periodicity schedules after appropriate consultations, or may adopt a nationally recognized schedule, such as Bright Futures ( http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf Exit Disclaimer Bright Futures also provides tools for screening ( http://brightfutures.aap.org/tool_and_resource_kit.html Exit Disclaimer The optimal EHR system will facilitate compliance with Bright Futures or state-developed recommendations using prompts, based on currently due preventive services as well as previously missed services. For example, prompts should take into account missed immunizations or missed blood-lead testing. Screening is a core component of preventive care. Abnormal screening results require follow-up care and some services require periodic rescreening, even when the previous screen was normal.

Examples of age- and gender-specific physical findings: There are a variety of age- and gender-specific physical findings that should be documented positively and negatively, including descended testes, infant hip-click/clunk, red-reflex, corneal light reflex, sacral dimple, and spine abnormalities. Physical exam findings (positive or negative associated with developmental dysplasia of the hip (e.g., Ortolani test or Barlow test are important to document in infancy but generally not thereafter. Tanner Staging is important beginning in early adolescence and varies between males and females.
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Last Updated 04/13/2016
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