Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coor
CPT4 code
Name of the Procedure:
Initial Nursing Facility Care, Per Day, for the Evaluation and Management of a Patient
Summary
This procedure involves a comprehensive assessment and management plan for patients newly admitted to a nursing facility. It includes taking a detailed medical history, performing a thorough physical examination, and making moderate-complexity medical decisions. This initial evaluation is crucial for establishing an appropriate care plan.
Purpose
The procedure addresses the medical and nursing needs of patients admitted to a nursing facility. The goal is to develop an effective care plan that manages the patient’s existing conditions and ensures their overall well-being during their stay at the facility.
Indications
- Recent admission to a nursing facility.
- Chronic health conditions requiring ongoing management.
Acute illness or a significant change in health status.
Appropriate for patients in need of a thorough initial assessment to create a tailored care plan.
Preparation
Patients and caregivers should:
- Provide comprehensive medical history, including current medications and allergies.
Follow any specific preparation instructions given by the facility, such as bringing previous medical records.
No specific fasting or pre-procedure tests are generally required unless specified by the healthcare provider.
Procedure Description
- Comprehensive History: The nurse or physician gathers detailed information about the patient’s medical, surgical, family history, and current medications.
- Comprehensive Examination: A full physical exam is conducted, covering all bodily systems to identify any issues.
- Medical Decision Making: Based on the history and examination, the medical team makes moderate-complexity decisions regarding treatment plans, necessary interventions, and coordination of care.
Tools and Equipment
- Standard examination tools (stethoscope, blood pressure cuff, thermometer, etc.).
- Patient records and information systems.
Anesthesia or Sedation
- Not applicable.
Duration
Usually takes between 60-90 minutes.
Setting
Performed in the nursing facility where the patient has been admitted.
Personnel
- Physician
- Registered Nurse (RN)
- Nursing Assistants
- Possibly other healthcare professionals (e.g., physical therapists, dietitians)
Risks and Complications
- Minimal risks, generally associated with the accuracy of the assessment and minor discomfort during the examination.
- Rarely, misdiagnosis or oversight of medical issues can occur.
Benefits
- Development of a personalized care plan.
- Early identification and management of health conditions.
- Improved coordination of care.
Recovery
- No specific recovery period as this is a non-invasive evaluation.
- Patients should follow the care plan and attend any recommended follow-up appointments.
Alternatives
- Outpatient evaluation prior to admission.
Telehealth initial assessment if in-person evaluation is not possible.
Alternatives might lack the thoroughness of an in-person, comprehensive evaluation.
Patient Experience
- The patient may feel some initial anxiety but overall should be comfortable.
- Communication with the healthcare team can help manage any concerns.
- Pain management is typically unnecessary as the procedure is non-invasive.
Counseling and coordination of care are integral parts of this process to ensure the patient and caregivers understand the care plan and next steps.