Summary of 2020 EPSDT Medical Record Review | TN Practice Matters

Last update: April 15, 2021

The annual 2020 EPSDT medical record review was conducted for each of the 3 Tennessee grand regions. A total of 45 providers were included in the review, with a total of 135 individual charts reviewed. The average score of all 3 regions combined was 94%. The elements most frequently not documented and identified as opportunities for improvement were Vaccines and Physical Exams. Please refer to the 2020 American Academy of Pediatrics (AAP) and Bright Futures Recommendations for Preventive Pediatric Health Care for current guidelines.

Vaccines

Vaccines are expected to be given during the EPDST screenings at the appropriate ages according to the Centers for Disease Control and Prevention (CDC) immunization schedule unless there is a contraindication or parent refusal noted. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. If a parent/guardian declines a vaccination, that should be noted in the chart.

Physical exams

When a comprehensive physical examination is performed, it must include documentation that the child was suitably draped or unclothed during the exam from newborn through age 20. All 7 required components of an EPSDT exam must be completed and documented in detail at each EPSDT visit.

In addition to documenting those elements, please remember dental referrals are to occur no later than age 3 or earlier if necessary. Each of the elements should be addressed during a TennCare Kids well-child exam when appropriate, and all findings should be documented.