The Health Practitioner Physical Assessment Form is designed for use by a range of health care providers, including primary physicians, certified nurse practitioners, registered nurses, certified nurse-midwives, or physician assistants, to document a comprehensive physical assessment of a resident. It covers various aspects of a resident's well-being, from medical and psychiatric history to nutritional status and cognitive functions. Each component of the assessment aims to identify the specific care needs of residents, ensuring they receive appropriate support in assisted living environments. For a detailed analysis and personalized care plan, ensure the form is filled out promptly by clicking the button below.
In the realm of health care, particularly for residents in assisted living facilities, the Health Practitioner Physical Assessment form serves as a comprehensive tool designed to gather crucial health information. This document, meant to be filled out by a qualified health care practitioner—be it a primary physician, certified nurse practitioner, registered nurse, certified nurse-midwife, or physician assistant—plays a pivotal role in ensuring that the individual care needs of each resident are met while adhering to the regulatory requirements set forth by Maryland regulations. These regulations stipulate that assisted living programs cannot accommodate residents requiring continuous nursing care among other specific health care needs unless they are under the care of a licensed general hospice program. The form meticulously captures a resident's medical and psychiatric history, noting recent health or behavioral changes and chronic conditions, thereby flagging any "triggers" that awake overnight staff should be aware of. Additionally, it includes sections on allergies, communicable diseases, substance use, fall risk factors, skin condition, sensory impairments, nutritional status, cognitive and behavioral status, and the resident's capacity to self-administer medication. It even delves into the resident's abilities concerning health care decision-making and medication administration, which significantly impacts the planning and delivery of personalized care. Furthermore, prescribers are given space to detail medication and treatment orders, highlighting the necessity of a tailored approach in managing each resident's health. The meticulous design of the form underscores the importance of a thorough physical assessment in promoting the well-being and safety of residents within an assisted living setting.
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Resident Name __________________________________
Date Completed ______________________
Date of Birth ____________________________________
Health Care Practitioner Physical Assessment Form
This form is to be completed by a primary physician, certified nurse practitioner, registered nurse, certified nurse- midwife or physician assistant. Questions noted with an asterisk are “triggers” for awake overnight staff.
Please note the following before filling out this form: Under Maryland regulations an assisted living program may not provide services to a resident who, at the time of initial admission, as established by the initial assessment, requires: (1) More than intermittent nursing care; (2) Treatment of stage three or stage four skin ulcers; (3) Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; (5) Monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6) Treatment for a disease or condition that requires more than contact isolation. An exception to the conditions listed above is provided for residents who are under the care of a licensed general hospice program.
1.* Current Medical and Psychiatric History. Briefly describe recent changes in health or behavioral status, suicide attempts, hospitalizations, falls, etc., within the past 6 months.
2.* Briefly describe any past illnesses or chronic conditions (including hospitalizations), past suicide attempts, physical, functional, and psychological condition changes over the years.
3.Allergies. List any allergies or sensitivities to food, medications, or environmental factors, and if known, the nature of the problem (e.g., rash, anaphylactic reaction, GI symptom, etc.). Please enter medication allergies here and also in Item 12 for medication allergies.
4.Communicable Diseases. Is the resident free from communicable TB and any other active reportable airborne communicable disease(s)?
(Check one)
Yes
No If “No,” then indicate the communicable disease: ________________________
Which tests were done to verify the resident is free from active TB?
PPD
Date: __________
Result:___________mm
Chest X-Ray (if PPD positive or unable to administer a PPD)
Result_____________
Form 4506 Revised 9-15-09
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5.History. Does the resident have a history or current problem related to abuse of prescription, non-prescription, over-the-counter (OTC), illegal drugs, alcohol, inhalants, etc.?
(a)Substance: OTC, non-prescription medication abuse or misuse
1.
Recent (within the last 6 months)
No
2.
History
(b)Abuse or misuse of prescription medication or herbal supplements
Currently
(c)History of non-compliance with prescribed medication
(d)Describe misuse or abuse: _________________________________________________________
____________________________________________________________________________________
6.* Risk factors for falls and injury. Identify any conditions about this resident that increase his/her risk of falling or
injury (check all that apply): orthostatic hypotension osteoporosis gait problem impaired
balance confusion Parkinsonism foot deformity pain assistive devices other (explain)
__________________________________________________________________________________________
7.* Skin condition(s). Identify any history of or current ulcers, rashes, or skin tears with any standing treatment
orders. _________________________________________________________________________________
8.* Sensory impairments affecting functioning. (Check all that apply.)
(a) Hearing:
Left ear:
Adequate
Poor
Deaf
Uses corrective aid
(b) Vision:
Right ear:
Uses corrective lenses
Blind (check all that apply) -
R
L
(c) Temperature Sensitivity:
Normal
Decreased sensation to:
Heat
Cold
9. Current Nutritional Status.
Height
inches
Weight
lbs.
(a) Any weight change (gain or loss)
in the
past 6 months?
(b) How much weight change?
lbs. in the past
months (check one)
Gain
Loss
(c) Monitoring necessary? (Check one.)
If items (a), (b), or (c) are checked, explain how and at what frequency monitoring is to occur: ___________
(d) Is there evidence of malnutrition or risk for undernutrition?
(e)* Is there evidence of dehydration or a risk for dehydration?
(f) Monitoring of nutrition or hydration status necessary?
If items (d) or (e) are checked, explain how and at what frequency monitoring is to occur: _______________
(g)Does the resident have medical or dental conditions affecting: (Check all that apply)
Chewing Swallowing Eating Pocketing food Tube feeding
(h)Note any special therapeutic diet (e.g., sodium restricted, renal, calorie, or no concentrated sweets restricted): _________________________________________________________________________________
(i)Modified consistency (e.g., pureed, mechanical soft, or thickened liquids): _________________________
(j) Is there a need for assistive devices with eating (If yes, check all that apply):
Weighted spoon or built up fork
Plate guard
Special cup/glass
(k) Monitoring necessary? (Check one.)
If items (g), (h), or (i) are checked, please explain how and at what frequency monitoring is to occur:
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10.* Cognitive/Behavioral Status.
(a)* Is there evidence of dementia? (Check one.)
(b) Has the resident undergone an evaluation for dementia? (c)* Diagnosis (cause(s) of dementia):
(d)Mini-Mental Status Exam (if tested)
Other
10(e)* Instructions for the following items: For each item, circle the appropriate level of frequency or intensity, depending on the item. Use the “Comments” column to provide any relevant details.
Item 10(e)
A
B*
C*
D*
Comments
Cognition
I. Disorientation
Never
Occasional
Regular
Continuous
II. Impaired recall
(recent/distant events)
III. Impaired judgment
IV. Hallucinations
V. Delusions
Communication
VI. Receptive/expressive
aphasia
Mood
and Emotions
VII. Anxiety
VIII. Depression
Behaviors
IX. Unsafe behaviors
X. Dangerous to self or
others
XI. Agitation (Describe
behaviors in comments
section)
10(f) Health care decision-making capacity. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, indicate this resident’s highest level of ability to make health care decisions.
(a) Probably can make higher level decisions (such as whether to undergo or withdraw life-sustaining treatments that require understanding the nature, probable consequences, burdens, and risks of proposed treatment).
(b) Probably can make limited decisions that require simple understanding.
(c) Probably can express agreement with decisions proposed by someone else.
(d) Cannot effectively participate in any kind of health care decision-making.
11.* Ability to self-administer medications. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, rate this resident’s ability to take his/her own medications safely and appropriately.
(a) Independently without assistance
(b) Can do so with physical assistance, reminders, or supervision only
(c) Need to have medications administered by someone else
___________________________________
________________
Print Name
Date
______________________________________
Signature of Health Care Practitioner
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PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION
Allergies (list all): ___________________________________________________________________________________________________________________
Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.
12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.
Include dosage route (p.o., etc.), frequency, duration (if limited).
12(b) All related diagnoses, problems, conditions.
Please include all diagnoses that are currently being treated by this medication.
12(c) Treatments (include frequency & any instructions about when to notify the physician).
Please link diagnosis, condition or problem as noted in prior sections.
12(d) Related testing or monitoring.
Include frequency & any instructions to notify physician.
Prescriber’s Signature ________________________________________________________
______________________________
Office Address ______________________________________________________________
Phone
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Filling out the Health Practitioner Physical Assessment form is a crucial step in the admission process for residents of assisted living programs in Maryland. This form is designed to ensure that residents receive appropriate care tailored to their specific health needs. It collects comprehensive information on the resident's medical and psychiatric history, allergies, communicable diseases, substance abuse history, fall risks, skin conditions, sensory impairments, nutritional status, cognitive and behavioral status, and their ability to self-administer medications. Accurately completing this form involves detailed knowledge of the resident’s health status and requires input from a primary physician, certified nurse practitioner, registered nurse, certified nurse-midwife, or physician assistant. Here’s how to fill it out step by step:
Remember to review each section carefully and provide thorough, accurate information. Your attention to detail is essential in ensuring the safety and well-being of the resident. Once completed, ensure that the health care practitioner signs and dates the form before submitting it as part of the resident’s admission documentation.
What is the purpose of the Health Practitioner Physical Assessment Form?
This form is designed for health care practitioners such as primary physicians, certified nurse practitioners, registered nurses, certified nurse midwives, or physician assistants to complete. It systematically assesses the health status of residents entering or residing in assisted living programs, ensuring that the level of care provided matches their medical, psychological, and nutritional needs.
Who can complete this form?
The form can be completed by authorized health care practitioners including primary physicians, certified nurse practitioners, registered nurses, certified nurse midwives, or physician assistants. This ensures that assessments are conducted by professionals with the requisite knowledge and expertise.
What information is required on the form?
The form requires detailed information on the resident's medical and psychiatric history, allergies, communicable diseases, drug or substance misuse, risk factors for falling, skin conditions, sensory impairments, nutritional status, cognitive and behavioral status, and ability to self-administer medications. It also includes sections for prescriber’s medication and treatment orders.
Are there any conditions that disqualify a resident from being admitted to an assisted living program?
Yes, under Maryland regulations, certain conditions disqualify a resident from being admitted at the time of initial assessment. These include needing more than intermittent nursing care, treatment of severe skin ulcers, ventilator services, skilled medication management for fluctuating conditions, uncontrollable chronic medical conditions, and diseases requiring more than contact isolation, except for residents under licensed general hospice care.
What are "trigger" questions on the form?
"Trigger" questions are marked with an asterisk (*) on the form and are designed to alert overnight staff to special needs or risks associated with a resident. These questions help in identifying residents who may require awake overnight care or monitoring.
How should allergies be reported on the form?
Allergies and sensitivities to foods, medications, or environmental factors should be clearly listed, along with the nature of the allergic reaction. Medication allergies must also be noted separately in the section designated for medication allergies to ensure they are prominently flagged for caregivers.
What details are needed for assessing risk factors for falls and injury?
The form requires checking all conditions that increase the risk of falls or injuries for a resident. This includes but is not limited to orthostatic hypotension, osteoporosis, gait problems, impaired balance, confusion, Parkinsonism, foot deformity, pain, and the use of assistive devices. Additional explanations can be provided if other risk factors exist.
How is the resident’s nutritional status evaluated?
The nutritional status is evaluated through questions about recent weight change, risk of malnutrition or undernutrition, dehydration risks, and the need for special diets or feeding assistance. Details on how and at what frequency monitoring should occur are requested if there are concerns.
What does the health care decision-making capacity section assess?
This section assesses the resident's ability to make health care decisions based on their cognitive and physical limitations. It looks at the resident's capability to make complex decisions, understand simple information, agree with decisions made by others, or if they are unable to participate in decision-making processes.
One common mistake made when filling out the Health Practitioner Physical Assessment form is the omission of comprehensive and recent medical history. It's crucial for the healthcare practitioner to include detailed and up-to-date information related to any recent changes in the resident's health or behavioral status. This encompasses notable changes within the past six months such as hospitalizations, falls, or any suicide attempts. Inadequately documenting these changes can hinder the continuity and quality of care provided to the resident.
Another oversight often encountered is the failure to adequately describe past illnesses, chronic conditions, and their evolution over time. The Health Practitioner Physical Assessment form requires a brief account of the resident's past health concerns, including any previous suicide attempts and changes in their physical, functional, and psychological condition over the years. Accurately capturing this information is pivotal, as it assists in crafting a tailored care plan that addresses all of the resident's needs.
Additionally, allergies are sometimes insufficiently detailed on the form. Specifically, the form asks for any sensitivities to food, medications, or environmental factors, along with the nature of the allergic reaction. Listing allergies without adequate descriptions of the reactions or failing to mention them in both the allergies section and the medications section (Item 12) can lead to potentially hazardous oversights in the resident's care regimen.
Furthermore, errors in reporting the resident's communicable disease status is a significant mistake. This part of the form is critical for preventing the spread of infectious diseases within the facility. It is essential to check the appropriate box indicating whether the resident is free from communicable tuberculosis (TB) and other airborne diseases and to provide documentation of tests verifying the resident's health status. Incomplete or incorrect information in this section can jeopardize the health and safety of both the resident and others in the facility.
When assessing the risk factors for falls and injuries, a common mistake is not thoroughly identifying all relevant conditions. The form lists several conditions that could increase the risk of falls or injuries, and it is imperative to consider and check all that apply to the resident. Overlooking components like orthostatic hypotension, gait problems, or impaired balance can lead to inadequate preventive measures within the care plan.
A related error is found in the assessment of skin conditions. While the form requires identification of any history of or current ulcers, rashes, or skin tears, including standing treatment orders, often, these are not comprehensively recorded. This negligence can delay wound care and proper skin management, exacerbating the resident's condition.
Errors in documenting sensory impairments, such as hearing and vision, also occur. These impairments significantly affect a resident's functioning and quality of life. Properly checking the boxes that accurately reflect the resident’s sensory capabilities and use of assistive devices like corrective lenses or aids is crucial for ensuring appropriate accommodations.
Lastly, the section concerning the resident's nutritional status and dietary needs is often filled out with inaccuracies or left incomplete. This part of the form is essential for identifying risks related to malnutrition or dehydration and for specifying any necessary dietary restrictions or need for assistive devices during meals. Detailed documentation in this section ensures that the resident receives the proper nutrition and hydration needed for their health and well-being.
When managing the care of individuals, especially in settings such as assisted living facilities or for those under home care, a Health Practitioner Physical Assessment form is a critical document. However, to ensure comprehensive care and adherence to regulatory requirements, this form is often accompanied by a set of other essential documents. These additional forms provide a broader perspective on the resident's health status, preferences, and specific care needs, facilitating a holistic approach to care planning and implementation.
Together, these documents complement the Health Practitioner Physical Assessment form, creating a comprehensive picture of a resident's health, capabilities, and care preferences. By diligently collecting and updating this information, care providers can offer personalized, effective care that respects the individual's wishes and meets their health needs.
The Health Practitioner Physical Assessment form closely resembles the Initial Patient Health History form, frequently used in medical offices for new patients. Both documents are aimed at gathering comprehensive health-related information, including medical and psychiatric history, to ensure proper care and treatment. The Health History form, similar to the Physical Assessment, often includes inquiries about past illnesses, surgeries, and chronic conditions, but it spans a broader lifetime history rather than focusing on the more recent six-month period.
Another document sharing similarities with the Health Practitioner Physical Assessment form is the Medication Administration Record (MAR). The section of the Physical Assessment form that deals with the resident’s ability to self-administer medications and any/all medication orders mirrors the MAR's purpose. Both documents track medication types, dosages, and frequencies, aiming to enhance patient safety by ensuring medications are administered correctly and consistently.
The Falls Risk Assessment form parallels the Health Practitioner Physical Assessment form in its focus on identifying risk factors for falls and injury. Both forms require the healthcare provider to evaluate and document specific conditions or factors that might increase the patient's risk of falling, such as gait problems, impaired balance, or orthostatic hypotension, with the objective of implementing preventive measures to mitigate these risks.
The Nutritional Assessment form also shares similarities with the Physical Assessment form, particularly in their mutual goal of evaluating and monitoring the patient's nutritional status. Both documents inquire about weight changes, risk of malnutrition or dehydration, and special dietary needs or modifications, focusing on ensuring the patient receives adequate nutrition and hydration as part of their overall care plan.
Substance Use History forms are akin to the Health Practitioner Physical Assessment form, especially in segments relating to the resident’s history or current issues with substance misuse or abuse. Both documents seek detailed information regarding the use of prescription, non-prescription, over-the-counter medications, illegal drugs, alcohol, and inhalants, to properly address and manage substance-related problems within the patient’s care plan.
The Skin Condition Assessment form is another document with a purpose similar to that of the Physical Assessment form, focusing specifically on identifying skin conditions such as ulcers, rashes, or tears. Both forms necessitate detailed information about any existing skin conditions and standing treatment orders, reflecting an emphasis on preventing and managing skin-related issues.
The Sensory Assessment form is comparable to sections of the Physical Assessment form that evaluate sensory impairments affecting functioning, like hearing and vision. Each document requires the healthcare provider to assess the level of sensory impairment and the use of any assistive devices, facilitating targeted interventions to support the patient’s sensory needs.
The Cognitive and Behavioral Assessment form overlaps with the Physical Assessment form in their collective objective to evaluate cognitive status and behavior. Both documents gather information on dementia, cognitive impairments, and behavioral issues, offering a baseline to develop personalized care plans that address these specific challenges.
The Dental Health Assessment form, while focusing on a more specific area of health, bears resemblance to the section of the Physical Assessment form related to medical or dental conditions affecting chewing, swallowing, and eating. Both documents emphasize the importance of identifying and managing oral health issues that could impact the patient's nutritional intake and overall well-being.
Lastly, the Pressure Ulcer Risk Assessment form shares a common aim with the Physical Assessment form, specifically in preventing and managing stage three or four skin ulcers through early identification of risk factors. Both documents facilitate a proactive approach to skin care, ensuring that at-risk patients receive appropriate interventions and monitoring.
When it comes to filling out the Health Practitioner Physical Assessment form, it is crucial to approach this task with care and precision. Here’s a quick guide to help you navigate through the do’s and don’ts effectively.
Many misconceptions exist regarding the Health Practitioner Physical Assessment form, and it’s crucial to address these misunderstandings to ensure accurate and efficient use of the form. Here are five common misconceptions and the explanations to clarify them:
Understanding these points clarifies the form's scope, applicability, and the roles of various healthcare professionals in completing it. It underlines the importance of a comprehensive approach to resident assessments in assisted living settings.
Filling out the Health Practitioner Physical Assessment form is a vital process that ensures the quality of care for residents in assisted living programs. There are several key takeaways for health practitioners to consider when completing this form:
Completing the Health Practitioner Physical Assessment form with thoroughness and accuracy is essential for developing a comprehensive care plan that addresses all aspects of a resident's health, safety, and well-being. The detailed sections of the form facilitate a multidimensional approach to assessing the needs of residents, ensuring that interventions are well-targeted and effective.
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