Form LIC602A "Physician's Report for Residential Care Facilities for the Elderly (Rcfe)" - California

What Is Form LIC 602A?

Form LIC 602A, Physician's Report for Residential Care Facilities for the Elderly (RCFE) - also known as the LIC Form 602A - is a form used to inform a residential care facility about the physical and mental condition of the resident or prospective resident. The form is issued by the California Department of Social Services Community Care Licensing Division and revised in August 2011. Click on the link below to download the fillable form.

The form is used as a part of Community Care Licensing program, as well as its related Form LIC 602, Physician's Report for Community Care Facilities. The latter is used to determine if the individual is eligible for admission or continued care in the community care facility.

The Physician's Report for Residential Care Facilities for the Elderly (RCFE) is a document that must be completed for each resident or prospective resident of a residential care facility for the elderly in California. The residential care facilities for the elderly licensed by the California Department of Social Services (CDSS) are required to provide basic supervision and non-medical care. The state-required form is an obligatory document that provides information about the care needs, diagnosis, and medical history of an elderly person. All these details allow determining whether the resident or prospective resident can receive the appropriate care in the non-medical facility.

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Form LIC 602A Instructions

The physician's report for RCFE should be completed either by the primary physician of the elderly individual or by an attending physician, in the case when the potential resident is in the hospital or in a skilled nursing community. It is recommended to ask the primary physician to fill out the form since they usually have a deeper understanding of their patients' mental and physical state and can provide more detailed information.

When filling out Form LIC 602A, every question must be answered. The physician can attach a separate sheet if the space provided is not enough to describe the medical condition of the patient.

The document itself consists of four parts:

  1. Part I. Facility Information. This part must be filled out by the licensee and contain the information about the residential care facility, including its name, full address, phone number, and license number. Besides, it requires the name and telephone number of the licensee;
  2. Part II. Resident/Patient Information. This part is completed by the resident and contains personal information: the name, date of birth, and age;
  3. Part III. Authorization for Release of Medical Information. By filling out this part the resident allows to disclose medical information to the residential care facility named in Part I;
  4. Part IV. Patient's Diagnosis. This is the most extensive part filled out by the elderly person's physician;
    1. Items 1 through 5. Contain the date of examination and basic information about the patient;
    2. Item 6. Tuberculosis (TB) Test. Must contain the details and results of the TB test, as well as the actions taken in the case of a positive test;
    3. Item 7. Primary Diagnosis. The item must contain the information about the patient's primary diagnosis, treatment prescribed, and patient's ability to manage the treatment;
    4. Item 8. Secondary Diagnosis. Requires the same information pertaining to secondary diagnosis;
    5. Item 9. Self-explanatory;
    6. Item 10. Contagious/Infectious Disease. If the patient has a contagious disease, the physician must describe treatment and medications prescribed;
    7. Item 11. Allergies. Contains information about the patient's allergies and treatment;
    8. Item 12. Other Conditions. Requires information about other health conditions of the patient;
    9. Item 13. Physical Health Status. The physician specifies if the patient has any of the listed statuses and provides necessary explanations;
    10. Item 14. Mental Condition. The physician indicates which mental condition the patient has and furnishes explanations;
    11. Item 15. Capacity for Self-Care. The physician must specify if the patient is capable fulfill basic self-care actions;
    12. Item 16. Medication Management. Requires information about medical actions the patient can perform;
    13. Item 17. Ambulatory Status. Should contain information about patient's ability to move;
    14. Item 18. Physical Health Status. Self-explanatory;
    15. Item 19. Comments. The physician can enter any additional information not indicated in the items above;
    16. Items 20 through 24. Self-explanatory.
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Download Form LIC602A "Physician's Report for Residential Care Facilities for the Elderly (Rcfe)" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)
I. FACILITY INFORMATION (To be completed by the licensee/designee)
1. NAME OF FACILITY
2. TELEPHONE
(
)
3. ADDRESS
CITY
ZIP CODE
4. LICENSEE’S NAME
5. TELEPHONE
6. FACILITY LICENSE NUMBER
(
)
II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person)
1. NAME
2. BIRTH DATE
3. AGE
III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(To be completed by resident/resident's legal representative)
I hereby authorize release of medical information in this report to the facility named above.
1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE
2. ADDRESS
3. DATE
IV. PATIENT'S DIAGNOSIS (To be completed by the physician)
NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a
residential care facility for the elderly licensed by the Department of Social Services. The license requires
the facility to provide primarily non-medical care and supervision to meet the needs of that person.
THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provide
about this person is required by law to assist in determining whether the person is appropriate for care in
this non-medical facility. It is important that all questions be answered.
(Please attach separate pages if needed.)
1. DATE OF EXAM
2. SEX
3. HEIGHT
4. WEIGHT
5. BLOOD PRESSURE
6. TUBERCULOSIS (TB) TEST
a. Date TB Test Given
b. Date TB Test Read c. Type of TB Test
d. Please Check if TB Test is:
Negative
Positive
e. Results: mm _____________
f. Action Taken (if positive): ________________________________
_________________________________________________________________________________
g. Chest X-ray Results: ________________________________________________________________
h. Please Check One of the Following:
Active TB Disease
Latent TB Infection
No Evidence of TB Infection or Disease
LIC 602A (8/11) (CONFIDENTIAL)
PAGE 1 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)
I. FACILITY INFORMATION (To be completed by the licensee/designee)
1. NAME OF FACILITY
2. TELEPHONE
(
)
3. ADDRESS
CITY
ZIP CODE
4. LICENSEE’S NAME
5. TELEPHONE
6. FACILITY LICENSE NUMBER
(
)
II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person)
1. NAME
2. BIRTH DATE
3. AGE
III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(To be completed by resident/resident's legal representative)
I hereby authorize release of medical information in this report to the facility named above.
1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE
2. ADDRESS
3. DATE
IV. PATIENT'S DIAGNOSIS (To be completed by the physician)
NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a
residential care facility for the elderly licensed by the Department of Social Services. The license requires
the facility to provide primarily non-medical care and supervision to meet the needs of that person.
THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provide
about this person is required by law to assist in determining whether the person is appropriate for care in
this non-medical facility. It is important that all questions be answered.
(Please attach separate pages if needed.)
1. DATE OF EXAM
2. SEX
3. HEIGHT
4. WEIGHT
5. BLOOD PRESSURE
6. TUBERCULOSIS (TB) TEST
a. Date TB Test Given
b. Date TB Test Read c. Type of TB Test
d. Please Check if TB Test is:
Negative
Positive
e. Results: mm _____________
f. Action Taken (if positive): ________________________________
_________________________________________________________________________________
g. Chest X-ray Results: ________________________________________________________________
h. Please Check One of the Following:
Active TB Disease
Latent TB Infection
No Evidence of TB Infection or Disease
LIC 602A (8/11) (CONFIDENTIAL)
PAGE 1 OF 6
7. PRIMARY DIAGNOSIS:
a.
Treatment/medication (type and dosage)/equipment:
b.
Can patient manage own treatment/medication/equipment?
Yes
No
c.
If not, what type of medical supervision is needed?
8. SECONDARY DIAGNOSIS(ES):
a.
Treatment/medication (type and dosage)/equipment:
b.
Can patient manage own treatment/medication/equipment?
Yes
No
c.
If not, what type of medical supervision is needed?
9. CHECK IF APPLICABLE TO 7 OR 8 ABOVE:
Mild Cognitive Impairment: Refers to people whose cognitive abilities are in a “conditional state”
between normal aging and dementia.
Dementia: The loss of intellectual function (such as thinking, remembering, reasoning, exercising
judgement and making decisions) and other cognitive functions, sufficient to interfere with an
individual’s ability to perform activities of daily living or to carry out social or occupational activities.
10. CONTAGIOUS/INFECTIOUS DISEASE:
a.
Treatment/medication (type and dosage)/equipment:
b.
Can patient manage own treatment/medication/equipment?
Yes
No
c.
If not, what type of medical supervision is needed?
LIC 602A (8/11) (CONFIDENTIAL)
PAGE 2 OF 6
11. ALLERGIES:
a.
Treatment/medication (type and dosage)/equipment:
b.
Can patient manage own treatment/medication/equipment?
Yes
No
c.
If not, what type of medical supervision is needed?
12. OTHER CONDITIONS:
a.
Treatment/medication (type and dosage)/equipment:
b.
Can patient manage own treatment/medication/equipment?
Yes
No
c.
If not, what type of medical supervision is needed?
13. PHYSICAL HEALTH STATUS
ASSISTIVE DEVICE
YES
NO
EXPLAIN
(If applicable)
a. Auditory Impairment
b. Visual Impairment
c. Wears Dentures
d. Wears Prosthesis
e. Special Diet
f. Substance Abuse Problem
g. Use of Alcohol
h. Use of Cigarettes
i. Bowel Impairment
j. Bladder Impairment
k. Motor Impairment/Paralysis
l. Requires Continuous
Bed Care
m. History of Skin Condition
or Breakdown
LIC 602A (8/11) (CONFIDENTIAL)
PAGE 3 OF 6
14. MENTAL CONDITION
YES
NO
EXPLAIN
a. Confused/Disoriented
b. Inappropriate Behavior
c. Aggressive Behavior
d. Wandering Behavior
e. Sundowning Behavior
f. Able to Follow Instructions
g. Depressed
h. Suicidal/Self-Abuse
i. Able to Communicate Needs
j. At Risk if Allowed Direct
Access to Personal
Grooming and Hygiene Items
k. Able to Leave Facility
Unassisted
15. CAPACITY FOR SELF-CARE
YES
NO
EXPLAIN
a. Able to Bathe Self
b. Able to Dress/Groom Self
c. Able to Feed Self
d. Able to Care for Own
Toileting Needs
e. Able to Manage Own
Cash Resources
YES
NO
EXPLAIN
16. MEDICATION MANAGEMENT
a. Able to Administer Own
Prescription Medications
b. Able to Administer Own
Injections
c. Able to Perform Own
Glucose Testing
d. Able to Administer Own
PRN Medications
e. Able to Administer Own
Oxygen
f. Able to Store Own
Medications
LIC 602A (8/11) (CONFIDENTIAL)
PAGE 4 OF 6
17. AMBULATORY STATUS:
a. 1. This person is able to independently transfer to and from bed:
Yes
No
2. For purposes of a fire clearance, this person is considered:
Ambulatory
Nonambulatory
Bedridden
Nonambulatory: A person who is unable to leave a building unassisted under emergency
conditions. It includes any person who is unable, or likely to be unable, to physically and mentally
respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating to
fire danger, and/or a person who depend upon mechanical aids such as crutches, walkers, and
wheelchairs.
Note: A person who is unable to independently transfer to and from bed, but who does not need
assistance to turn or reposition in bed, shall be considered non-ambulatory for the purposes of a
fire clearance.
Bedridden: For the purpose of a fire clearance, this means a person who requires assistance with
turning or repositioning in bed.
b. If resident is nonambulatory, this status is based upon:
Physical Condition
Mental Condition
Both Physical and Mental Condition
c. If a resident is bedridden, check one or more of the following and describe the nature of the illness,
surgery or other cause:
llness: ____________________________________________________________________
Recovery from Surgery: ______________________________________________________
Other: ____________________________________________________________________
NOTE: An illness or recovery is considered temporary if it will last 14 days or less.
d. If a resident is bedridden, how long is bedridden status expected to persist?
1. __________ (number of days)
2. ______________________ (estimated date illness or recovery is expected to end or when
resident will no longer be confined to bed)
3. If illness or recovery is permanent, please explain: __________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
LIC 602A (8/11) (CONFIDENTIAL)
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