Name of the Procedure:

Initial Nursing Facility Care per Day (Evaluation and Management)

Summary

This procedure involves a comprehensive assessment and management of a patient's health condition when they are first admitted to a nursing facility. A healthcare provider conducts a detailed or comprehensive history, an extensive examination, and straightforward medical decision-making.

Purpose

The primary goal is to evaluate the patient's overall health status, identify any immediate medical needs, and determine an appropriate care plan. This procedure helps in organizing and coordinating care to improve patient outcomes within the nursing facility.

Indications

• Admission to a nursing facility
• Need for comprehensive health evaluation
• Chronic illness management
• Acute medical condition requiring ongoing care
• Post-hospitalization recovery and monitoring

Preparation

• Ensure medical records are up to date
• Notify the facility staff of any specific patient needs
• No special fasting or medication adjustments are typically necessary
• Conduct any necessary preliminary diagnostic tests

Procedure Description

1. The healthcare provider reviews the patient's medical history in detail.
2. A comprehensive physical examination is performed to evaluate the patient's current health status.
3. Medical decision-making involves assessing the findings, considering patient preferences, and formulating a straightforward care plan.
4. The provider may prescribe medications, order additional tests, or refer to specialists as needed.

Duration

The initial evaluation and management can typically take between 30 to 60 minutes, depending on the complexity of the patient's condition.

Setting

This procedure is performed within a nursing facility, either in a patient’s room or a designated examination area.

Personnel

• Registered Nurses
• Nurse Practitioners or Physician Assistants
• Attending Physicians
• Other allied healthcare professionals as required

Risks and Complications

• Minimal risk associated with the evaluation and management process itself
• Potential for missing underlying conditions in an initial assessment
• Complications may arise from any new treatments or interventions prescribed based on the findings

Benefits

• Comprehensive health evaluation at the start of nursing facility care
• Early identification of medical issues and creation of a tailored care plan
• Enhanced coordination of care and improved health outcomes

Recovery

• No specific recovery needed from the evaluation procedure itself
• Follow-up assessments and care adjustments as needed
• Ongoing monitoring to ensure patient stability and progress

Alternatives

• Discharge planning and follow-up care in an outpatient setting
• Home health evaluations for patients who can be managed at home
• Pros and cons: On-site evaluations ensure immediate care access whereas outpatient or home care may require additional coordination.

Patient Experience

• Patients may feel anxious or uncomfortable during the initial assessment but should communicate any discomfort.
• Care providers can offer reassurance, pain management, and comfort measures as needed to ensure a positive experience.

By understanding these aspects, both healthcare providers and patients can ensure a thorough and effective initiation of care in a nursing facility, paving the way for improved patient health and well-being.