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Role of a Treating Physician for Long-Term Care Residents

Residents in long-term care facilities have the right to choose their treating physician. This right is supported in in federal and state law. See 42 C.F.R. § 483.10(d);  O.C.G.A. § 31-8-108(b)(1). As a practical matter, however, most physicians, don’t make house calls to the facility. This mean, by default, most residents are treated by the faciity medical director.

The Treating Physician Will:

  • Evaluate the patient and write a report detailing the physical examination within a certain number of days prior to admission or following admission. 42 C.F.R. § 483.20(a) says the facility must have physician orders for the resident’s immediate care.
  • Evaluate the patient as needed and at least every 30 days. An alternate schedule is permissible. The physician must document evaluations in the medical record. 42 C.F.R. § 483.30(c)
  • Supervise the patient’s care. 42 C.F.R. § 483.30(a). Evaluate the patient and review orders and treatment upon any change of physicians.
  • Determine the patient’s diagnoses.
  • Provide advice and treatment, and determine the appropriate level of care for each patient.
  • Write and sign orders for diet, care, diagnostic tests, and treatment of the patient by others.
  • Obtain the patient’s informed consent for the use of restraints and psychotropic medications.
  • Obtain informed consent from the patient or the patient’s health care agent in situations where a reasonable patient could not or would not be aware of the consequences of a given treatment decision without obtaining specific information from the physician. Determine what information is needed by the patient in order to make the consent meaningful.
  • Ensure that all care rendered by non-physician practitioners is legally authorized and that they are appropriately supervised.
  • Write progress notes and other appropriate entries in the patient’s chart. 42 C.F.R. § 483.30(b)(2).
  • Provide for alternate physician coverage if the attending physician is not available. 42 C.F.R. § 483.30(a)(2).

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