annual physician review of long term nursing home residents

Introduction

Includes:

• active medical problems
• medical history
  • acute medical problems within the past year
  • laboratory testing to monitor active disease
  • symptoms relevant to active medical disease
• medications
• review of systems
  • review symptoms common in nursing home patients
• physical examination
• functional status
  • current status & changes in:
    • basic activities of daily living (ADL)
    • mobility
    • continence
    • cognitive function
    • affective status
      • mood
      • behavior
  • assess rehabilitation potential (if relevant)
• social status
  • review family involvement, family concerns, family problems
• health maintenance
  • audiology
  • optometry/ophthalmology
  • dental
  • podiatry
  • tuberculosis testing
  • laboratory screening
  • radiology (mammography, if relevant)
• advance directives
  • existence of a directive
  • identification of proxy
  • can patient still make decisions regarding his/her health care?
  • intensity of care (code status)
• plan
  • overall goals for care
  • specific plans

Additional terms

• activities of daily living (ADL)
• health maintenance in nursing home patients
• medical progress notes on nursing home residents
• physician evaluation at nursing home admission