602 Form Details

In order to obtain a license in the state of California, you will need to complete the Lic 602A form. The form is used to provide information about your education and work experience. It is important to complete the form accurately and submit it on time. Failure to do so may result in delays or rejection of your application. For more information, visit our website today.

Below is the information in regards to the file you were in search of to fill out. It will show you the span of time you will need to complete lic 602a, what fields you need to fill in and a few other specific facts.

QuestionAnswer
Form NameLic 602A
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesphysician report residential care, form lic 602a, lic 602a, 602 form

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