43BMeaning of comprehensive medical assessment in item 712

43B Meaning of comprehensive medical assessment in item 712

(1) For item 712, a comprehensive medical assessment of a resident of a residential aged care facility is a full systems review of the resident, including an assessment of the resident’s health and physical and psychological function.

(2) A comprehensive medical assessment involves all of the following:

(a) a personal attendance by a medical practitioner;

(b) taking a detailed relevant medical history;

(c) conducting a comprehensive medical examination of the resident;

(d) developing a list of diagnoses and medical problems based on the medical history and examination;

(e) providing, for the resident’s records, a written summary of the outcomes of the assessment to inform the provision of care for the resident and to assist in the provision of medication management review services for the resident.

(3) A comprehensive medical assessment also includes:

(a) making a written summary of the comprehensive medical assessment; and

(b) providing a copy of the summary to the residential aged care facility; and

(c) offering the resident a copy of the summary or relevant parts of the summary.