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    Physician Evaluation

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    bartoncreekal
    This document contains a resident assessment form for a physician to evaluate the physical and medical status of a resident named at an assisted living facility. It includes sections to document the resident's medical history, vital signs, review of major body systems, current medications and the level of assistance needed, known allergies, required medical appointments and providers, physical and mental limitations, diet, communicable diseases, and standing orders for over-the-counter medications. The assessment guidelines at the end provide details on what should be examined for each body system.

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    Physician Evaluation

    Uploaded by

    bartoncreekal
    116 views6 pages
    This document contains a resident assessment form for a physician to evaluate the physical and medical status of a resident named at an assisted living facility. It includes sections to document the resident's medical history, vital signs, review of major body systems, current medications and the level of assistance needed, known allergies, required medical appointments and providers, physical and mental limitations, diet, communicable diseases, and standing orders for over-the-counter medications. The assessment guidelines at the end provide details on what should be examined for each body system.

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    This document contains a resident assessment form for a physician to evaluate the physical and medical status of a resident named at an assisted living facility. It includes sections to document the resident's medical history, vital signs, review of major body systems, current medications and the level of assistance needed, known allergies, required medical appointments and providers, physical and mental limitations, diet, communicable diseases, and standing orders for over-the-counter medications. The assessment guidelines at the end provide details on what should be examined for each body system.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    116 views6 pages

    Physician Evaluation

    Uploaded by

    bartoncreekal
    This document contains a resident assessment form for a physician to evaluate the physical and medical status of a resident named at an assisted living facility. It includes sections to document the resident's medical history, vital signs, review of major body systems, current medications and the level of assistance needed, known allergies, required medical appointments and providers, physical and mental limitations, diet, communicable diseases, and standing orders for over-the-counter medications. The assessment guidelines at the end provide details on what should be examined for each body system.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 6

    Barton Creek Assisted Living Type 1 & 2

    Resident Assessment
    Physician Evaluation

    Resident Name: ___________________________________ DOB: ____/____/________

    Physical Assessment

    Medical/Surgical History:

    Vital Signs:
     Temp. _____
     Pulse _____
     Resp. _____
     B/P _____/_____
     Weight_____

    Review of Systems: (Refer to Assessment Guidelines, Page 5)


     Integumentary

     Respiratory

     Cardiovascular

     Genitourinary

     Musculoskeletal

     Neurological

     Endocrine

     Pain

    1
    Medication Assessment

    Medication Name: Dosage: Route: Frequency:

    Level of Medication Assistance Needed:


     Independent – Requires no assistance or supervision, may keep under own control
    in own room.

     Needs assistance as indicated (check all that apply):


    o Reminder to take
    o Opening Container
    o Reading instructions on container label
    o Checking dosage against label
    o Reassure dosage is correct
    o Observe resident take medication as prescribed
    o Remind resident/responsible person when prescription needs to be refilled
    o Other: ______________________________________________________

    Known Medication Allergies:


    _______________________________________________________________________
    _

    Assess needed physician appointments and the person responsible to schedule, transport:
    _______________________________________________________________________
    _

    Assess needed laboratory work, responsible person to perform and transport:


    _______________________________________________________________________
    _

    2
    Assess outside health care providers e.g. independent health care professional and/or
    home health agency. Identify service(s) and provider(s) with name and phone number:
    _______________________________________________________________________
    _______________________________________________________________________
    __

    Describe physical limitations:


    _______________________________________________________________________
    _

    Describe mental limitations:


    _______________________________________________________________________
    _

    Assess diet regimen, food allergies, preferences, and dislikes:


    _______________________________________________________________________
    _

    Is the resident free of communicable diseases? _____ If no, please explain:


    _______________________________________________________________________
    _

    Physician Signature: __________________________________ Date: ____/____/____


    Address: _______________________________
    Office Phone: (____) _____________________
    Emergency #: (____) _____________________

    Identify other practitioners for referral:

    Dentist: _____________________________________________
    Address: _______________________________
    Office Phone: (____) _____________________
    Emergency #: (____) _____________________

    Other practitioners:

    3
    O.T.C. Medication Standing Orders

    The Nurse at Barton Creek Assisted Living may use his/her judgment to administer over
    the counter medications and treatments. If the problem or condition persists beyond
    seventy-two hours, a physician will be notified and a script will be obtained. Family
    members or responsible parties will be notified by the nurse if it is necessary to
    implement a standing order into regular administration.

    The following over the counter medications and treatments may be used per label
    instructions and utilizing the above stipulations. Please initial which of the following
    will become standing orders within the resident’s record.

    _____ Tylenol 325 i-ii (pain, fever)


    _____ Ibuprofen 200 mg i-ii (pain, fever)
    _____ Milk of Magnesia 300 cc (constipation)
    _____ Dulcolax suppository 10 mg (constipation)
    _____ Tums (gastric distress)
    _____ Immodium 2mg (diarrhea)
    _____ Urinalysis (increased confusion, concentrated urine, elevated temperature,
    frequent urination, burning sensation upon urination)

    Patient Name: _____________________________________ DOB: ___/___/_____


    RN Signature: _____________________________________ Date: ___/___/_____
    Physician Signature: ________________________________ Date: ___/___/_____

    4
    Assessment Guidelines

    Integumentary System: assessment will include skin color, skin temperature, skin
    integrity, turgor and condition of mucous membranes.
    Normal Findings: skin color good/within norm; skin warm/dry/intact; no skin problems:
    mucous membranes moist/pink.

    Respiratory System: assessment will include quality/characteristics of respiration; lung/


    breath sounds; cough/sputum; color of mail beds/mucous membranes.
    Normal Findings: respirations quiet/easy/regular; RR 10-20/min. at rest; breath sounds
    vesicular through both lung fields; bronchial over major airways with no adventitious
    sounds; no cough/sputum clear; nail beds & mucous membranes pink; no other problems.

    Cardiovascular System: assessment will include peripheral pulses/apical pulse; chest


    pain; edema; calf tenderness; cardiac rhythm/sound.
    Normal Findings: peripheral pulses palpable, resent and strong; regular apical pulse: no
    chest pain; neck vein flat/no distention; no edema; no calf tenderness; S1 and S2 audible
    and regular; no other cardiac problems.

    Gastrointestinal System: assessment will include appearance/palpation of abdomen;


    bowel sounds; bowel pattern/stools/appetite; diet tolerance; fluid intake/weight/nausea
    and vomiting.
    Normal Findings: abdomen soft; bowel sounds present and active; no pain or palpation;
    fair to good appetite; tolerates diet without nausea and vomiting; adequate fluid intake;
    no weight loss or gain; normal bowel movement, pattern and consistency.

    Musculoskeletal System: assessment will include joint swelling, tenderness ROM


    limitations, muscle strength and condition of surrounding tissue.
    Normal Findings: absence of joint swelling and tenderness, normal ROM on all joints; no
    muscle weakness; no ADL problems; no activity or functional limitations; no evidence of
    inflammation, nodules, ulcerations or rashes.

    Neurological System: assessment will include orientation, pupils, movement/gait,


    sensation, quality of speech/swallowing, memory, sleep pattern, seizures, vision, hearing.
    Normal Findings: alert and oriented to person, place, and time; PERIL; active ROM of all
    extremities with symmetry of strength; no paresthesia; no seizures; verbalization clear
    and understandable, memory intact; normal gait; normal swallowing/gag reflex; regular
    sleep pattern; no visual or hearing impairment.

    5
    Endocrine System: assessment will include presence of diabetes, thyroid problems or
    other endocrine dysfunctions.
    Normal Findings: Absence of thyroid or endocrine problems and other endocrine
    dysfunctions; no diabetes.

    Pain Assessment: will include presence of pain; the resident’s description, location,
    duration, intensity, radiation, precipitating factors and alleviating factors.
    Normal Findings: Document if medication relieves pain.

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