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annual physician review of long term nursing home residents
Includes:
1) active medical problems
2) medical history
a) acute medical problems within the past year
b) laboratory testing to monitor active disease
c) symptoms relevant to active medical disease
3) medications
4) review of systems
-> review symptoms common in nursing home patients
5) physical examination
6) functional status
a) current status & changes in:
1] basic activities of daily living (ADL)
2] mobility
3] continence
4] cognitive function
5] affective status
a] mood
b] behavior
b) assess rehabilitation potential (if relevant)
7) social status
-> review family involvement, family concerns, family problems
8) health maintenance
a) audiology
b) optometry/ophthalmology
c) dental
d) podiatry
e) tuberculosis testing
f) laboratory screening
g) radiology (mammography, if relevant)
9) advance directives
a) existence of a directive
b) identification of proxy
c) can patient still make decisions regarding his/her health care?
d) intensity of care (code status)
10) plan
a) overall goals for care
b) specific plans
Related
activities of daily living (ADL)
health maintenance in nursing home patients
medical progress notes on nursing home residents
physician evaluation at nursing home admission
References
- Ouslander JG, Osterweil D.
Physician evaluation and management of nursing home residents.
Ann Intern Med 120:584, 1994
PMID: 8116998