LIC 602A PDF Details

By paying attention to these considerations below, in addition to filling out the form carefully, you will contribute to a more accurate and effective evaluation of whether the residential care facility is the right environment for the elderly individual in question.

Confidentiality: This form contains sensitive medical information. Make sure it is handled, stored, and transmitted in a manner compliant with healthcare privacy laws such as HIPAA.

Physician Qualifications: The form should be filled out by a physician who is knowledgeable about the patient's medical history and current health status.

Attachments and Additional Notes: If the space provided in the form is insufficient for any of the sections, make sure to attach separate pages clearly indicating to which section they belong.

Legal Authorization: Before medical information can be shared, the resident or their legal representative must authorize it. Without this, the form is not valid.

Updates and Re-assessments: Conditions of residents may change over time. Hence, you may need to revisit and potentially update this form to reflect the current health status of the resident.

Non-Medical Facility: Remember, RCFEs are not skilled nursing facilities. The form specifically points out that the care provided is primarily non-medical, so ensure the resident's needs align with the services the facility can offer.

Question	Answer
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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