Name of the Procedure:

Subsequent Nursing Facility Care, per Day, for the Evaluation and Management of a Patient

Summary

This medical procedure involves daily evaluations and management of a patient in a nursing facility. It requires at least two of these three key components: an expanded problem-focused interval history, an expanded problem-focused examination, and medical decision-making.

Purpose

This procedure addresses chronic or complex medical conditions that require ongoing monitoring and management. The primary goal is to ensure the patient’s well-being, manage symptoms, and adjust treatment plans as necessary.

Indications

• Patients with chronic illnesses such as diabetes, hypertension, or COPD.
• Individuals recovering from surgery or severe illness.
• Patients who require ongoing medical management and frequent reassessment.
• Elderly or disabled patients needing comprehensive care.

Preparation

• No specific preparations like fasting or medication adjustments are typically required.
• Patients may need to have recent medical records and any existing treatment plans available for review.
• Diagnostic tests or assessments done recently should be accessible to the healthcare team.

Procedure Description

1. Introductory Assessment: The healthcare provider reviews the patient's medical history, including any changes since the last evaluation.
2. Expanded Problem-Focused Interval History: The provider takes a detailed history, focusing on changes or developments in the patient's condition.
3. Expanded Problem-Focused Examination: A thorough physical examination is conducted, targeting areas of concern.
4. Medical Decision Making: The provider assesses the information gathered, makes clinical judgments, and updates the care plan as needed.

Tools or Equipment:

• Stethoscope, blood pressure cuff, and other basic medical examination tools.
• Medical records and recent diagnostic test results.

Duration

Typically, each session lasts between 20 to 40 minutes, depending on the patient's condition and needs.

Setting

This procedure is performed in a nursing facility, such as a skilled nursing home or a long-term care facility.

Personnel

• Primary healthcare provider, usually a physician, nurse practitioner, or physician assistant.
• Nursing staff for support and implementation of the care plan.

Risks and Complications

• As this is primarily an evaluation and management procedure, risks are minimal.
• There may be discomfort during physical examinations.
• Possible adverse reactions if new medications or treatments are introduced.

Benefits

• Continuous monitoring and management of chronic or complex conditions.
• Timely adjustments to treatment plans improve patient outcomes.
• Enhanced overall health and quality of life for long-term care patients.

Recovery

• No significant recovery time required.
• Patients should follow the daily care plans and attend all scheduled evaluations.
• Ensure any prescribed treatments or medications are taken as directed.

Alternatives

• Home healthcare visits: Provide similar care in a patient's home, but with different logistics.
• Outpatient clinic visits: Patients can visit a clinic for evaluation and management, but may not receive daily care.
• Telehealth: Remote consultations can substitute for in-person evaluations but may be less comprehensive.

Patient Experience

• Patients might feel reassured through regular monitoring and adjustments to their care plan.
• Minimal discomfort from necessary physical examinations.
• Enhanced comfort by receiving care in the familiar setting of the nursing facility.