A comprehensive unclothed physical examination is an essential part of each preventive health visit and is a required EPSDT service.

Physical examinations should be performed according to the HealthCheck Periodicity Schedule

During the exam, infants should be totally unclothed and older children should be undressed and suitably draped in a light gown.

The examination consists of a systematic inspection of all parts of the body. The general appearance of the child should also be noted to determine overall health status.

Documenting the Physical Examination

Thoroughly document all aspects of the unclothed physical exam using the Standard Medical Record Form (SMRF) (link opens in new window).

Specific Areas of Note in Filling Out the SMRF (from SMRF training):

Every item in the (unclothed) physical exam must be reviewed and marked NL (normal) or ABN (abnormal). Additional text may be written in space provided

Read more about Documentation Required for Compliance with HealthCheck (link opens in new window).

(Note: this image is taken from SMRF #3: 6 to 9 months old visits; forms for other age ranges may differ slightly).