Lic 602A – Fill Out and Use

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

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.)

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)

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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)

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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)

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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)

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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)

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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)

LIC 602A (8/11) (CONFIDENTIAL)

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