Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Cou
CPT4 code
Name of the Procedure:
Annual Nursing Facility Assessment (Technical: Evaluation and Management Service)
Summary
An Annual Nursing Facility Assessment is a structured evaluation conducted each year to monitor the health and well-being of residents in a nursing facility. It includes taking a detailed history of the patient's condition since the last assessment, performing a thorough physical examination, and making medical decisions based on the findings, with complexity ranging from low to moderate.
Purpose
This assessment aims to identify any new health concerns, monitor ongoing conditions, and adjust care plans accordingly to ensure optimal health and quality of life for nursing facility residents.
Indications
- Routine annual check-up for nursing facility residents.
- Patients with chronic conditions requiring annual evaluations.
- Residents with complex medical histories needing comprehensive monitoring.
Preparation
- No specific preparation is usually required.
- Patients should bring a list of current medications and any recent medical records.
- Ensure the patient or their guardian is aware of the appointment.
Procedure Description
- Detailed Interval History: The healthcare provider gathers comprehensive information about any new symptoms, changes in health status, and updates on ongoing medical issues since the last assessment.
- Comprehensive Examination: A thorough physical examination is conducted, covering all major organ systems to assess the patient's overall health.
- Medical Decision Making: Based on the gathered information and examination results, the provider develops or updates the care plan. This could include adjusting medications, ordering further diagnostic tests, or recommending specialist consultations.
Tools and equipment involved may include:
- Stethoscope
- Blood pressure cuff
- Thermometer
- Basic diagnostic tools (ophthalmoscope, otoscope, reflex hammer)
- Patient's medical records
No anesthesia or sedation is required, as this is a non-invasive procedure.
Duration
Typically takes about 30 to 60 minutes.
Setting
Performed within the nursing facility in the patient's living space or a designated medical office.
Personnel
- Licensed Physician or Nurse Practitioner (Primary Evaluator)
- Nursing staff (Assist with history taking and physical examination)
Risks and Complications
- Minimal risks as this is a non-invasive assessment.
- Rarely, minor discomfort during the physical examination.
Benefits
- Early detection of new or worsening conditions.
- Updated and optimized care plans for better management of health.
- Enhanced quality of life through timely medical interventions.
Recovery
- No recovery time required.
- Immediate resumption of regular activities.
- Follow-up appointments or interventions may be scheduled based on findings.
Alternatives
- More frequent assessments for patients with rapidly changing health statuses.
- In-home evaluations by visiting healthcare providers for less mobile patients.
These alternatives may offer closer monitoring but can be more resource-intensive.
Patient Experience
Patients might feel at ease with the familiar nursing facility environment and the presence of their regular healthcare providers. Some might experience mild discomfort during specific parts of the physical exam. Ongoing communication and empathetic care from the healthcare team help ensure patient comfort and understanding.