Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Co
CPT4 code
Name of the Procedure:
Domiciliary or Rest Home Visit for Evaluation and Management of an Established Patient
Summary
A domiciliary or rest home visit involves a healthcare provider traveling to the patient's home or rest facility to evaluate and manage health concerns. It is tailored for patients with limited mobility or those who require ongoing medical supervision in a non-hospital setting.
Purpose
The procedure addresses chronic, acute, or complex health conditions in patients who cannot easily travel to a medical facility. The goal is to provide timely and convenient medical care, monitor ongoing health issues, and make straightforward medical decisions based on the patient's current status.
Indications
- Chronic illness management
- Post-operative care
- Mobility limitations or disability
- Patients requiring routine medical monitoring
- Conditions that require regular medical assessments
Preparation
- Patients should keep a list of current medications handy.
- No specific preparation like fasting is typically required.
- Recent medical records or test results should be available for the healthcare provider.
Procedure Description
- The healthcare provider arrives at the patient's home or rest facility at a scheduled time.
- A problem-focused interval history is taken, addressing recent symptoms or changes in health.
- A problem-focused examination is conducted, which may include vital signs, physical examination, and specific tests pertaining to the patient's condition.
- Straightforward medical decision-making, involving diagnosis, treatment plans, or adjustments to medications, is carried out based on the findings.
- Documentation and any necessary referrals or prescriptions are completed.
Tools: Stethoscope, blood pressure cuff, otoscope, portable diagnostic tools (if needed), medical records. Anesthesia: Not applicable.
Duration
Typically, 30 to 60 minutes per visit.
Setting
Patient's home, rest home, or assisted living facility.
Personnel
- Primary care physician or nurse practitioner
- May involve a nurse or medical assistant for support
Risks and Complications
- Minimal risks involved; mainly dependent on the patient's underlying conditions.
- Potential for missing out on specialized diagnostic facilities available at a medical center.
Benefits
- Convenient care in a familiar environment.
- Improved access to medical evaluations, leading to timely interventions.
- Personalized care tailored to the patient's unique health needs.
Recovery
- No specific recovery required.
- Follow-up care instructions will be provided.
- Scheduled follow-up visits or referrals to specialists if needed.
Alternatives
- Clinic visits: Requires patient to travel but offers access to more extensive diagnostic facilities.
- Telemedicine consultations: Convenient but may lack the thoroughness of a physical examination.
Patient Experience
- The patient can expect personalized attention in a comfortable setting.
- Minimal to no discomfort during the visit.
- Clear communication regarding their health status and next steps for management.