Lic 602A – Fill Out and Use This PDF

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

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

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

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

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

_________________________________________________________________________________

g.Chest X-ray Results: ________________________________________________________________

h.Please Check One of the Following:

7.PRIMARY DIAGNOSIS:

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

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

8.SECONDARY DIAGNOSIS(ES):

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

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:

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

11.ALLERGIES:

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

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

12.OTHER CONDITIONS:

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

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

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

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:

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:

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: __________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

e. Is resident receiving hospice care?

20. PHYSICIAN'S NAME AND ADDRESS (PRINT)