Annual Physical Exam Standard 12 Comprehensive Medical Service Delivery: Documentation: The medical needs of the person should be addressed by the Annual Physical Documentation of primary care provider. This can include a physician, Exam: person’s comprehensive Annual physical nurse practitioner or assistant. Annually, the physician’s health services exams are required for primary care provider should complete a thorough physical including health all people receiving assessment as needed for the age, gender and person’s assessments, lab, supports and services general physical health and provide a summary of the diagnostic, and from DDA, unless assessment and any recommendations in writing. (See screening tests, and otherwise Medical Evaluation Form in Appendix.) specialty documented, in consultations will writing, by the Consultations with specialists will usually be ordered by the be maintained in primary care primary care provider, but any changes to the person’s the health record. physician. medical plan of care should be coordinated with the primary care provider. Documentation from the specialty consult must be shared with the primary care physician. The PCP in Applies to: All people receiving turn should document in writing that they have reviewed the supports and services results of these consults and any follow-up as recommended through DDA. by the PCP. Any decision to decline a recommendation should also be documented including rationale. All laboratory and procedural reports should be obtained and placed with the record as quickly as possible. The person’s primary care provider must be notified of any laboratory tests not within normal limits. Recommendations for general medical care, specialty care, and medical follow-up should be carried out by the residential service provider, within the time frame prescribed by the physician and/or specialist. Annual medical assessments are to include: All medical and psychiatric diagnoses Current medications Recent illness profile History Physical exam Laboratory test results. The assessment is to be appropriate for the age and gender of the person, and tailored to the special characteristics/needs of
Standard 12 Annual Physical Exam: Annual physical exams are required for all people receiving supports and services from DDA, unless otherwise documented, in writing, by the primary care physician. Applies to: All people receiving supports and services through DDA. Annual Physical Exam Comprehensive Medical Service Delivery: The medical needs of the person should be addressed by the person’s primary care provider. This can include a physician, nurse practitioner or physician’s assistant. Annually, the primary care provider should complete a thorough physical assessment as needed for the person’s age, gender and general physical health and provide a summary of the assessment and any recommendations in writing. (See Medical Evaluation Form in Appendix.) Consultations with specialists will usually be ordered by the primary care provider, but any changes to the person’s medical plan of care should be coordinated with the primary care provider. Documentation from the specialty consult must be shared with the primary care physician. The PCP in turn should document in writing that they have reviewed the results of these consults and any follow-up as recommended by the PCP. Any decision to decline a recommendation should also be documented including rationale. All laboratory and procedural reports should be obtained and placed with the person’s record as quickly as possible. The primary care provider must be notified of any laboratory tests not within normal limits. Recommendations for general medical care, specialty care, and medical follow-up should be carried out by the residential service provider, within the time frame prescribed by the physician and/or specialist. Annual medical assessments are to include: All medical and psychiatric diagnoses Current medications Recent illness profile History Physical exam Laboratory test results. The assessment is to be appropriate for the age and gender of the person, and tailored to the special characteristics/needs of Documentation: Documentation of comprehensive health services including health assessments, lab, diagnostic, and screening tests, and specialty consultations will be maintained in the health record.
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