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History and Physical

History and Physical 

 

History: 

Chief Complaint:  __________________________________________________________________ 

History of Present Illness:  ___________________________________________________________ 

________________________________________________________________________________ 

Family/Social History:  ______________________________________________________________ 

DNR Status Review:   _______________________________________________________________ 

Continue DNR  [      ] 

Past Medical History or Update on Progress from Past Year:  _______________________________ 

________________________________________________________________________________ 

Resident’s Medical Stability/Prognosis:  ________________________________________________ 

 

Physical Exam/Review of Systems 

 

 

Normal 

Abnormal 

Comments 

Skin 

 

 

 

 

Head 

 

 

 

 

Eyes 

 

 

 

 

Ears 

 

 

 

 

Nose 

 

 

 

 

Throat 

 

 

 

 

Neck 

 

 

 

 

Breast 

 

 

 

 

Lungs/Chest 

 

 

 

 

Cardiac 

 

 

 

 

Abdomen 

 

 

 

 

Rectal 

 

 

 

Stool for Occult Blood: 

GU 

 

 

 

 

Pelvic 

 

 

 

 

Extremities 

 

 

 

 

Vascular 

 

 

 

 

Neurological/ 

Psychiatric 

 

 

 

Oral Cavity 

 

 

 

 

 

Resident’s Name:  _______________________________________ Admission Date:  ________________________ 

 

 

Physician Signature:  _____________________________________ Date:  _________________________________ 

 

References: 

  • Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. [Link to current CMS SOM] 

  • CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines] 

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