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

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 actual document 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.