Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Cou
CPT4 code
Name of the Procedure:
Subsequent Nursing Facility Care
Common name(s): Nursing Home Visit, Follow-Up Nursing Home Evaluation
Technical term: Subsequent Nursing Facility Care, per day
Summary
Subsequent nursing facility care involves daily evaluation and management of a patient in a nursing home. This care includes at least two of the following key components: a problem-focused interval history, a problem-focused examination, and straightforward medical decision-making.
Purpose
The purpose of this daily care is to monitor and manage the health of patients residing in nursing facilities. The goal is to address and stabilize any ongoing health issues, manage chronic conditions, and ensure the patient’s overall well-being.
Indications
- Ongoing chronic conditions like diabetes or heart disease
- Recent hospital discharge requiring follow-up
- Acute illnesses such as infections
- Post-operative care
- Palliative care needs
Preparation
- Ensure the patient has access to their medical records for a comprehensive review.
- No specific fasting or medication adjustments are generally required.
Procedure Description
- Problem-Focused Interval History: Gathering information about changes in the patient's condition since the last visit.
- Problem-Focused Examination: Conducting a physical examination targeting the patient's specific health issues.
- Straightforward Medical Decision Making: Analyzing the collected data and determining the necessary care steps. Decision-making is based on the straightforwardness of the patient’s condition and requires minimal analytical complexity.
Tools used may include a stethoscope, blood pressure cuff, thermometer, and any other necessary diagnostic tools. Anesthesia or sedation is not required.
Duration
Each visit typically takes about 15 to 30 minutes.
Setting
The procedure is performed in a nursing facility, such as a nursing home or long-term care center.
Personnel
- Physician
- Nurse Practitioner
- Registered Nurse
- Certified Nursing Assistant
Risks and Complications
- Minimal risks involved, mainly related to the accuracy of the diagnosis.
- Rare complications may include mismanagement of chronic conditions if not properly monitored.
Benefits
- Continuous monitoring and tailored management of health issues.
- Early detection and treatment of new or worsening conditions.
- Enhanced quality of life through coordinated care.
Recovery
- No specific recovery period needed, as this is a routine check.
- Patients may need to follow specific instructions based on their health condition.
- Follow-up care as determined by the healthcare professional.
Alternatives
- Home health visits for patients who are not in nursing facilities.
- Outpatient visits to a primary care provider.
- Telemedicine consultations.
Patient Experience
- Patients might feel reassured by ongoing care and attention to their health needs.
- Physical examination and history-taking are typically non-invasive and cause minimal discomfort.
- Comfort measures include making sure the patient is relaxed and comfortable during the visit.
Pain management is usually not necessary as the procedures involved in the evaluation are non-invasive.