Physician Evaluation

Barton Creek Assisted Living Type 1 & 2 Resident Assessment Physician Evaluation Resident Name: ___________________________________ DOB: ____/____/________

Physical Assessment Medical/Surgical History:

Vital Signs:  Temp. _____ 

Pulse _____

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Resp. _____

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B/P

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Weight_____

_____/_____

Review of Systems: (Refer to Assessment Guidelines, Page 5)  Integumentary 

Respiratory

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Cardiovascular

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Genitourinary

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Musculoskeletal

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Neurological

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Endocrine

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Pain

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Medication Assessment Medication Name:

Dosage:

Route:

Frequency:

Level of Medication Assistance Needed:  Independent – Requires no assistance or supervision, may keep under own control in own room.  Needs assistance as indicated (check all that apply): o Reminder to take o Opening Container o Reading instructions on container label o Checking dosage against label o Reassure dosage is correct o Observe resident take medication as prescribed o Remind resident/responsible person when prescription needs to be refilled o Other: ______________________________________________________ Known Medication Allergies: _______________________________________________________________________ _ Assess needed physician appointments and the person responsible to schedule, transport: _______________________________________________________________________ _ Assess needed laboratory work, responsible person to perform and transport: _______________________________________________________________________ _

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Assess outside health care providers e.g. independent health care professional and/or home health agency. Identify service(s) and provider(s) with name and phone number: _______________________________________________________________________ _______________________________________________________________________ __ Describe physical limitations: _______________________________________________________________________ _ Describe mental limitations: _______________________________________________________________________ _ Assess diet regimen, food allergies, preferences, and dislikes: _______________________________________________________________________ _ Is the resident free of communicable diseases? _____ If no, please explain: _______________________________________________________________________ _ Physician Signature: __________________________________ Date: ____/____/____ Address: _______________________________ Office Phone: (____) _____________________ Emergency #: (____) _____________________ Identify other practitioners for referral: Dentist: _____________________________________________ Address: _______________________________ Office Phone: (____) _____________________ Emergency #: (____) _____________________ Other practitioners:

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O.T.C. Medication Standing Orders The Nurse at Barton Creek Assisted Living may use his/her judgment to administer over the counter medications and treatments. If the problem or condition persists beyond seventy-two hours, a physician will be notified and a script will be obtained. Family members or responsible parties will be notified by the nurse if it is necessary to implement a standing order into regular administration. The following over the counter medications and treatments may be used per label instructions and utilizing the above stipulations. Please initial which of the following will become standing orders within the resident’s record. _____ Tylenol 325 i-ii (pain, fever) _____ Ibuprofen 200 mg i-ii (pain, fever) _____ Milk of Magnesia 300 cc (constipation) _____ Dulcolax suppository 10 mg (constipation) _____ Tums (gastric distress) _____ Immodium 2mg (diarrhea) _____ Urinalysis (increased confusion, concentrated urine, elevated temperature, frequent urination, burning sensation upon urination) Patient Name: _____________________________________ RN Signature: _____________________________________ Physician Signature: ________________________________

DOB: ___/___/_____ Date: ___/___/_____ Date: ___/___/_____

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Assessment Guidelines Integumentary System: assessment will include skin color, skin temperature, skin integrity, turgor and condition of mucous membranes. Normal Findings: skin color good/within norm; skin warm/dry/intact; no skin problems: mucous membranes moist/pink. Respiratory System: assessment will include quality/characteristics of respiration; lung/ breath sounds; cough/sputum; color of mail beds/mucous membranes. Normal Findings: respirations quiet/easy/regular; RR 10-20/min. at rest; breath sounds vesicular through both lung fields; bronchial over major airways with no adventitious sounds; no cough/sputum clear; nail beds & mucous membranes pink; no other problems. Cardiovascular System: assessment will include peripheral pulses/apical pulse; chest pain; edema; calf tenderness; cardiac rhythm/sound. Normal Findings: peripheral pulses palpable, resent and strong; regular apical pulse: no chest pain; neck vein flat/no distention; no edema; no calf tenderness; S1 and S2 audible and regular; no other cardiac problems. Gastrointestinal System: assessment will include appearance/palpation of abdomen; bowel sounds; bowel pattern/stools/appetite; diet tolerance; fluid intake/weight/nausea and vomiting. Normal Findings: abdomen soft; bowel sounds present and active; no pain or palpation; fair to good appetite; tolerates diet without nausea and vomiting; adequate fluid intake; no weight loss or gain; normal bowel movement, pattern and consistency. Musculoskeletal System: assessment will include joint swelling, tenderness ROM limitations, muscle strength and condition of surrounding tissue. Normal Findings: absence of joint swelling and tenderness, normal ROM on all joints; no muscle weakness; no ADL problems; no activity or functional limitations; no evidence of inflammation, nodules, ulcerations or rashes. Neurological System: assessment will include orientation, pupils, movement/gait, sensation, quality of speech/swallowing, memory, sleep pattern, seizures, vision, hearing. Normal Findings: alert and oriented to person, place, and time; PERIL; active ROM of all extremities with symmetry of strength; no paresthesia; no seizures; verbalization clear and understandable, memory intact; normal gait; normal swallowing/gag reflex; regular sleep pattern; no visual or hearing impairment.

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Endocrine System: assessment will include presence of diabetes, thyroid problems or other endocrine dysfunctions. Normal Findings: Absence of thyroid or endocrine problems and other endocrine dysfunctions; no diabetes. Pain Assessment: will include presence of pain; the resident’s description, location, duration, intensity, radiation, precipitating factors and alleviating factors. Normal Findings: Document if medication relieves pain.

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