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 high complexity. Counseling and/or coordina
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 evaluation and management of a patient in a nursing facility. It requires a detailed history, an extensive physical examination, and medical decision-making of high complexity. Counseling and coordination of care may also be part of the process.
Purpose
The goal of this procedure is to thoroughly assess the patient's medical condition, devise a highly complex medical care plan, and initiate treatment to address any acute or chronic issues. This initial care helps in setting a baseline for ongoing management in a nursing facility.
Indications
- New admission to a nursing facility
- Acute or chronic medical conditions requiring detailed evaluation
- Complex care management needs
- Significant changes in a patient's health status that require comprehensive assessment
Preparation
- Patients may need to provide a detailed medical history and list of current medications.
- No specific physical preparation (like fasting) is usually required.
- Diagnostic tests or previous medical records should be available for review.
Procedure Description
- Comprehensive History: A complete review of the patient's medical, surgical, and family history, along with current medications and allergies.
- Comprehensive Examination: Head-to-toe physical examination assessing all major organ systems.
- Medical Decision Making: High complexity decision-making involving the diagnosis, management options, and coordination of care, considering the complete clinical picture.
- Counseling: Discussing the care plan, answering questions, and providing guidance to the patient and family.
- Coordination of Care: Working with other healthcare providers to develop a cohesive treatment plan.
Duration
The comprehensive assessment and evaluation typically take between 60-90 minutes.
Setting
The procedure is performed in a nursing facility (either a skilled nursing facility or a long-term care facility).
Personnel
- Primary care physician or specialist
- Registered nurse or nurse practitioner
- Other healthcare providers as needed (e.g., physical therapist, dietitian)
Risks and Complications
- Risk of missing information if medical history is incomplete
- Potential for stress or fatigue in patients during evaluation
- Rare risk of miscommunication among multiple healthcare providers
Benefits
- Thorough assessment leads to accurate diagnosis and effective care plans.
- Better coordination of care helps in managing complex medical needs.
- Immediate and long-term health benefits through tailored treatment strategies.
Recovery
- No special recovery is needed post-evaluation.
- Patients should follow the care plan and any specific instructions provided.
- Regular follow-up visits will be scheduled to monitor progress and adjust the care plan as needed.
Alternatives
- Outpatient comprehensive evaluations, though less convenient for non-ambulatory patients.
- Telemedicine evaluations, subject to limitations in physical exams.
- Home health services for those unable to attend a nursing facility.
Patient Experience
- Patients might feel tired due to the length and detail of the assessment.
- Comfort measures are taken to minimize discomfort.
- Open communication with healthcare providers to ensure understanding and manage any concerns or anxiety.