LIC 602A PDF Details

The State of California, through its Health and Human Services Agency and Department of Social Services, requires a comprehensive evaluation for individuals considering residency in Residential Care Facilities for the Elderly (RCFE). The LIC 602A form, a crucial document in this process, serves multiple essential functions. It first collects fundamental information about the facility and the prospective or current resident. The form mandates the consent of the resident or their legal representative for the release of medical information, ensuring respect for privacy and personal rights. A significant section is dedicated to the physician's report, which assesses various health parameters of the resident, including primary and secondary diagnoses, TB test results, allergies, other conditions, and overall physical and mental health status. This assessment is vital for determining the appropriateness of a non-medical residential care setting for the individual’s needs, emphasizing the fact that RCFEs do not offer skilled nursing care. Furthermore, it evaluates the resident’s capacity for self-care, medication management, and ambulatory status, which impacts their care plan and the facility’s ability to adequately meet their needs. In essence, the LIC 602A form bridges the gap between medical evaluation and non-medical residential care, ensuring a match that supports the resident's health, safety, and wellbeing.

QuestionAnswer
Form Name LIC 602A
Form Length 6 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 1 min 30 sec
Other names lic 602a, form residential care rcfe, form lic 602a

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)

I.FACILITY INFORMATION (To be completed by the licensee/designee)

1.

NAME OF FACILITY

 

 

 

2. TELEPHONE

 

 

 

 

 

(

)

 

 

 

 

 

 

 

3.

ADDRESS

 

CITY

 

 

ZIP CODE

 

 

 

 

4.

LICENSEE’S NAME

5. TELEPHONE

6. FACILITY LICENSE NUMBER

 

 

(

)

 

 

 

 

 

 

 

 

 

 

II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person)

1. NAME

2. BIRTH DATE

3. AGE

 

 

 

III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (To be completed by resident/resident's legal representative)

I hereby authorize release of medical information in this report to the facility named above.

1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE

2. ADDRESS

3. DATE

IV. PATIENT'S DIAGNOSIS (To be completed by the physician)

NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a residential care facility for the elderly licensed by the Department of Social Services. The license requires the facility to provide primarily non-medical care and supervision to meet the needs of that person. THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provide about this person is required by law to assist in determining whether the person is appropriate for care in this non-medical facility. It is important that all questions be answered.

(Please attach separate pages if needed.)

1. DATE OF EXAM

2. SEX

3. HEIGHT

4. WEIGHT

5. BLOOD PRESSURE

6. TUBERCULOSIS (TB) TEST

a. Date TB Test Given

b. Date TB Test Read

c. Type of TB Test

d. Please Check if TB Test is:

 

 

 

■ Negative

■ Positive

 

 

 

 

 

e. Results: mm _____________ f. Action Taken (if positive): ________________________________

_________________________________________________________________________________

g.Chest X-ray Results: ________________________________________________________________

h.Please Check One of the Following:

■ Active TB Disease

■ Latent TB Infection

■ No Evidence of TB Infection or Disease

LIC 602A (8/11) (CONFIDENTIAL)

PAGE 1 OF 6

7.PRIMARY DIAGNOSIS:

a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? ■ Yes

■ No

c.If not, what type of medical supervision is needed?

8.SECONDARY DIAGNOSIS(ES):

a.Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? ■ Yes

■ No

c.If not, what type of medical supervision is needed?

9.CHECK IF APPLICABLE TO 7 OR 8 ABOVE:

■Mild Cognitive Impairment: Refers to people whose cognitive abilities are in a “conditional state” between normal aging and dementia.

■Dementia: The loss of intellectual function (such as thinking, remembering, reasoning, exercising judgement and making decisions) and other cognitive functions, sufficient to interfere with an individual’s ability to perform activities of daily living or to carry out social or occupational activities.

10.CONTAGIOUS/INFECTIOUS DISEASE:

a.Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? ■ Yes

■ No

c.If not, what type of medical supervision is needed?

LIC 602A (8/11) (CONFIDENTIAL)

PAGE 2 OF 6

11.ALLERGIES:

a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? ■ Yes

■ No

c.If not, what type of medical supervision is needed?

12.OTHER CONDITIONS:

a.Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? ■ Yes

■ No

c.If not, what type of medical supervision is needed?

13. PHYSICAL HEALTH STATUS

YES

NO

ASSISTIVE DEVICE

EXPLAIN

 

 

 

 

 

(If applicable)

 

 

a. Auditory Impairment

 

 

 

 

 

 

 

 

 

 

 

b. Visual Impairment

 

 

 

 

 

 

 

 

 

 

 

c. Wears Dentures

 

 

 

 

 

 

 

 

 

 

 

d. Wears Prosthesis

 

 

 

 

 

 

 

 

 

 

 

 

e.

Special Diet

 

 

 

 

 

 

 

 

 

 

 

 

f.

Substance Abuse Problem

 

 

 

 

 

 

 

 

 

 

 

 

g.

Use of Alcohol

 

 

 

 

 

 

 

 

 

 

 

 

h.

Use of Cigarettes

 

 

 

 

 

 

 

 

 

 

 

 

i.

Bowel Impairment

 

 

 

 

 

 

 

 

 

 

 

 

j.

Bladder Impairment

 

 

 

 

 

 

 

 

 

 

 

 

k.

Motor Impairment/Paralysis

 

 

 

 

 

 

 

 

 

 

 

 

l.

Requires Continuous

 

 

 

 

 

 

Bed Care

 

 

 

 

 

 

 

 

 

 

 

m. History of Skin Condition

 

 

 

 

 

 

or Breakdown

 

 

 

 

 

 

 

 

 

 

 

LIC 602A (8/11) (CONFIDENTIAL)

PAGE 3 OF 6

14. MENTAL CONDITION

YES

NO

EXPLAIN

 

a. Confused/Disoriented

 

 

 

 

 

 

 

 

 

b. Inappropriate Behavior

 

 

 

 

 

 

 

 

 

c. Aggressive Behavior

 

 

 

 

 

 

 

 

 

d. Wandering Behavior

 

 

 

 

 

 

 

 

 

e. Sundowning Behavior

 

 

 

 

 

 

 

 

 

 

f.

Able to Follow Instructions

 

 

 

 

 

 

 

 

 

 

g.

Depressed

 

 

 

 

 

 

 

 

 

 

h.

Suicidal/Self-Abuse

 

 

 

 

 

 

 

 

 

 

i.

Able to Communicate Needs

 

 

 

 

 

 

 

 

 

 

j.

At Risk if Allowed Direct

 

 

 

 

 

Access to Personal

 

 

 

 

 

Grooming and Hygiene Items

 

 

 

 

 

 

 

 

 

 

k.

Able to Leave Facility

 

 

 

 

 

Unassisted

 

 

 

 

 

 

 

 

15. CAPACITY FOR SELF-CARE

YES

NO

EXPLAIN

 

 

 

 

 

 

a. Able to Bathe Self

 

 

 

 

 

 

 

 

 

b. Able to Dress/Groom Self

 

 

 

 

 

 

 

 

 

c. Able to Feed Self

 

 

 

 

 

 

 

 

 

d. Able to Care for Own

 

 

 

 

 

Toileting Needs

 

 

 

 

 

 

 

 

 

e. Able to Manage Own

 

 

 

 

 

Cash Resources

 

 

 

 

 

 

 

 

16. MEDICATION MANAGEMENT

YES

NO

EXPLAIN

a.Able to Administer Own Prescription Medications

b.Able to Administer Own Injections

c.Able to Perform Own Glucose Testing

d.Able to Administer Own PRN Medications

e.Able to Administer Own Oxygen

f.Able to Store Own Medications

LIC 602A (8/11) (CONFIDENTIAL)

PAGE 4 OF 6

17. AMBULATORY STATUS:

a. 1. This person is able to independently transfer to and from bed: ■ Yes

■ No

2. For purposes of a fire clearance, this person is considered:

 

■ Ambulatory

■ Nonambulatory

■ Bedridden

 

Nonambulatory: A person who is unable to leave a building unassisted under emergency conditions. It includes any person who is unable, or likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating to fire danger, and/or a person who depend upon mechanical aids such as crutches, walkers, and wheelchairs.

Note: A person who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be considered non-ambulatory for the purposes of a fire clearance.

Bedridden: For the purpose of a fire clearance, this means a person who requires assistance with turning or repositioning in bed.

b. If resident is nonambulatory, this status is based upon:

■ Physical Condition

■ Mental Condition

■ Both Physical and Mental Condition

c.If a resident is bedridden, check one or more of the following and describe the nature of the illness, surgery or other cause:

■llness: ____________________________________________________________________

■Recovery from Surgery: ______________________________________________________

■Other: ____________________________________________________________________

NOTE: An illness or recovery is considered temporary if it will last 14 days or less.

d.If a resident is bedridden, how long is bedridden status expected to persist?

1.__________ (number of days)

2.______________________ (estimated date illness or recovery is expected to end or when resident will no longer be confined to bed)

3.If illness or recovery is permanent, please explain: __________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

LIC 602A (8/11) (CONFIDENTIAL)

PAGE 5 OF 6

e. Is resident receiving hospice care?

 

■ No

■ Yes If yes, specify the terminal illness: ________________________________

18.

PHYSICAL HEALTH STATUS:

■ Good

■ Fair

■ Poor

19.

COMMENTS:

 

 

 

 

20. PHYSICIAN'S NAME AND ADDRESS (PRINT)

21.TELEPHONE

( )

22. LENGTH OF TIME RESIDENT HAS BEEN YOUR PATIENT

23. PHYSICIAN'S SIGNATURE

24. DATE

LIC 602A (8/11) (CONFIDENTIAL)

PAGE 6 OF 6

How to Edit LIC 602A Online for Free

It won't be challenging to complete lic 602a rcfe applying our PDF editor. Here's how you can rapidly create your form.

Step 1: Choose the "Get Form Here" button.

Step 2: After you have accessed the lic 602a rcfe editing page you can find every one of the actions you can carry out about your template at the top menu.

Feel free to type in the following information to create the lic 602a rcfe PDF:

part 1 to completing lic 602a physician's report

In the section ADDRESS, DATE, IV PATIENTS DIAGNOSIS To be, NOTE TO PHYSICIAN The person named, DATE OF EXAM, SEX, HEIGHT WEIGHT BLOOD PRESSURE, TUBERCULOSIS TB TEST a Date TB, and d Please Check if TB Test is enter the information the software demands you to do.

part 2 to finishing lic 602a physician's report

It is crucial to put down specific particulars inside the box e Results mm, f Action Taken if positive, g Chest Xray Results, h Please Check One of the Following, Active TB Disease Latent TB, LIC A CONFIDENTIAL, and PAGE OF.

Filling in lic 602a physician's report part 3

The a Treatmentmedication type and, b Can patient manage own, If not what type of medical, SECONDARY DIAGNOSISES, a Treatmentmedication type and, and b Can patient manage own field enables you to point out the rights and responsibilities of all sides.

lic 602a physician's report a Treatmentmedication type and, b Can patient manage own, If not what type of medical, SECONDARY DIAGNOSISES, a Treatmentmedication type and, and b Can patient manage own fields to insert

Fill out the form by checking the next sections: If not what type of medical, CHECK IF APPLICABLE TO OR ABOVE, between normal aging and dementia, Dementia The loss of intellectual, CONTAGIOUSINFECTIOUS DISEASE, a Treatmentmedication type and, and b Can patient manage own.

part 5 to entering details in lic 602a physician's report

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