PHYSICAL ASSESSMENT

1. At the time of admission, a preliminary physical assessment shall be done, at a minimum by an RN, or LPN under the supervision of a RN or physician, and shall include:

• Vital signs documentation

• Appropriate screening test for STD and TB

• Urine drug screen for drugs of abuse

• Determination of whether the patient requires a physical or psychiatric exam by a physician according to this protocol

• Any laboratory tests as clinically indicated

2. Any physical examination performed is done within a reasonable time, as determined by the patient’s medical condition, and, as consistent with this policy’s criteria (4 and 5, below).

3. The admission assessment includes a review of the circumstances leading to admission, mental status, support system, psychiatric and medical history, risk assessment for HIV, history of use of drugs and alcohol, including the age of onset, duration, patterns and consequences of use, family history of drug and alcohol use, routes of administration, and previous treatment.

4. The results of a physical exam within 6 months of admission may be used to assess physical status if there is no significant change in the physical status of the patient. Further assessments or lab tests may be required depending on the modality of treatment needed or the patient’s changing condition.

5. Physician Referral Criteria: The following categories of Recovery.Works patients are required to have a physical assessment reviewed by a physician:

a. Patients receiving spa or sauna treatments involving heat immersion therapy are required to be cleared by a physician before their participation.

b. A physical exam is necessary for pregnant females.

c. Patients without medical clearance, who meet Admission Exclusion Criteria (see 111.8.19.13.1a) must be evaluated by a physician before eligibility for entry into the program.

d. Patients with difficulty tolerating or coping with physical problems, or other biomedical problems, patients with problems that may interfere with their recovery and mental health treatment may require physician assessment referral taking into account any circumstances related to

• the history of the condition,

• its stability,

• any prior medical evaluation(s),

• recommendations, and

• treatment history.

e. Where medical treatment stabilization is needed, patients with medical problems that have been neglected prior to admission are referred for physician evaluation.

f. Patients requiring prescription medication who are not already being satisfactorily followed by a physician are referred for physician evaluation.

g. Patients exhibiting psychiatric decompensation are referred for psychiatric evaluation, taking into account any current symptoms, or changes in symptoms, e.g.,

• Hallucinations

• Delusions

• Suicidal thoughts

• Homicidal thoughts

• Violent impulses

• Severe distractibility or impulsivity

Evaluation for treatment at a higher level of care is done for acute decompensation patients.

This includes evaluation for the presence of suicidal ideation, violent impulses, or significant history of suicidal or violent behavior that requires more than routine monitoring.

Activities to address the substance use disorder may need to be postponed until the patient’s mental health symptoms are better stabilized.

h. Patients exhibiting psychiatric symptoms that significantly affect recovery efforts require psychiatric evaluation, e.g.,

• Uncontrolled behavior, confusion, or disorientation limiting the patient’s capacity for self-care; inadequate ability to manage the activities of daily living.

• Acute course of illness dominates the clinical presentation. Symptoms may include impairments in

• Reality testing

• Communication

• Thought processes

• Judgment

• Attention to personal hygiene

• Symptoms significantly compromise the patient’s ability to adjust his or life in the community.

• Patients with limited ability to follow through with treatment recommendations to the extent of demonstrating a risk of, or vulnerability to dangerous consequences