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 

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]