Physician’s Visit Report
Resident:
Date:
Time:
Record ID #:
Physician:
Current Status:  Digression  Improvement  No Change  Levels of Care Assessment
Symptoms or Reason for Visit:
Transported by:
Activities leading to symptoms (if any):
List of Medications: (or see MAR)
Pharmacy:
List Vitamins, Minerals, Herbs, or other over the counter remedies the resident takes:
Completed By:
PHYSICIAN’S COMMENTS
►New Diagnosis (if any):
►Are any medical tests needed?
►Were any new medications ordered on this visit? (Please attach prescription)
If yes, what is the purpose of the new medication?
► Was information on the new medication faxed or sent to the pharmacy?  Yes
 No
Other Treatment Options Offered or Suggested:
Risks:
Benefits:
Side Effects:
The above treatment options  were or  were not explained to the resident and/or the responsible party.
►Please Explain New Orders, information, precautions or special needs the resident
may have:
►Follow up Visit needed?  Yes  No
►Physician’s Signature:
If yes, Appt Date:
Time:
Date:
CC 8.19