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

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

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

1. NAME OF FACILITY

Telephone

Address

Street Address

Street Address Line 2

CityState / Province

Postal / 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

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

TUBERCULOSIS (TB) TEST

a. Date TB Test Given

Date

b. Date TB Test Read

Date

C. Type of TB Test

D. Please Check if TB Test is:

NegativePositive

e. Results

f. Action Taken (if positive)

g. Chest X ray Results

h. Please Check One of the Following

Active TB DiseaseLatent TB InfectionNo Evidence of TB Infection or Disese

7. PRIMARY DIAGNOSIS:

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

b.Can patient manage own treatment/medication/equipment?

YesNo

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?

YesNo

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?

YesNo

If not, what type of medical supervision is needed?

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

11. ALLERGIES:

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

b.Can patient manage own treatment/medication/equipment?

YesNo

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?

YesNo

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

13. PHYSICAL HEALTH STATUS

	YES	NO	ASISSTIVE DEVICE	EXPLAIN
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

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 Instruction
g. Depressed
h. Suicidal / Self - Abuse
i. Able to Communicate Needs
j. At Risk if Allowed Direct Access to Personal Grooming & 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

17. AMBULATORY STATUS:

a. 1. This person is able to independently transfer to and from bed

YesNo

2. For purpose of a fire clearance, this person is considered:

AmbulatoryNonambulatoryBedridden

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 ConditionMental ConditionBoth 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

Ilness: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)

(estimate date illness or recovery is expected to end when resident will no longer be confined to bed)

3. If illness or recovery is permanent, please explain

LIC 602A (8/11) (CONFIDENTIAL)

e. Is resident receiving hospice care?

NoYes

If yes, specify the terminal illness

18. PHYSICAL HEALTH STATUS

GoodFairPoor

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

Date

LIC 602A (8/11) (CONFIDENTIAL)