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PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE (California)

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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
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
YES
NO
ASSISTIVE DEVICE
(If applicable)
EXPLAIN
LIC 602A (8/11) (CONFIDENTIAL) PAGE 3 OF 6
14 YES NO
EXPLAIN
. MENTAL CONDITION
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
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
YES NO
EXPLAIN
LIC 602A (8/11) (CONFIDENTIAL) PAGE 4 OF 6
Bedridden
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
17. AMBULATORY STATUS:
a.
1. This person is able to independently transfer to and from bed:
■
Ye s
■
No
2. For purposes of a fire clearance, this person is considered:
■ Ambulatory
■ Nonambulatory
■
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 clear
ance, 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. D
ATE
LIC 602A (8/11) (CONFIDENTIAL) PAGE 6 OF 6
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PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE (California)

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Completed 4 June 2021

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