Fla. Admin. Code Ann. R. 63M-2.0048 - Comprehensive Physical Assessment (CPA)
(1) The Comprehensive Physical Assessment (HS 007)
shall be completed no later than seven (7) calendar days following the date of
admission. For youth with a Comprehensive Physical Assessment completed prior
to admission, see subsection
63M-2.0048(9),
F.A.C.
(2) The DHA/designee may
place the youth on a 72-hour observation with no contact sports or extensive
exercise regimen. Attempts shall be made to interview the parent/legal
guardian/assigned custodian to determine any current physical activity
restrictions in effect prior to admission to detention. Youth shall be screened
for chronic health conditions that may potentially prevent participation in
strenuous physical activity. Youth who are re-admitted to detention will be
screened for history of known physical activity restrictions post practitioner
assessment during the prior admission. If there are no symptoms that would
warrant concern for participation in activity during the 72 hours, the activity
restriction may be lifted after consulting with the practitioner or at the
completion of the CPA.
(3) Youth in
detention who are released pending placement in a Residential Commitment
Program are to have a CPA completed prior to release from detention, or
documentation of a current CPA completed.
(4) The standard Comprehensive Physical Assessment
(CPA) form shall be used by all practitioners. The Comprehensive Physical
Assessment (HS 007, February 2024) is incorporated into this rule and is
available electronically at
http://www.flrules.org/Gateway/reference.asp?No=Ref-17501.
When a community practitioner completes the CPA, (physician, PA, or APRN), all
efforts shall be made to provide them with the approved form for documentation.
If this cannot be done, the DHA, his/her physician designee, PA or APRN shall
augment that assessment to ensure that all of the CPA's required components are
clearly documented on the alternate form.
(5) A new CPA, or a focused medical examination
documented in the chronological progress notes, shall be completed as
clinically indicated when a youth's condition warrants.
(a) At a minimum, a focused note must be completed
with each additional admission and completion of the Additional Reviews to
Comprehensive Physical Assessment form (HS 052).
(b) All screening components (i.e., vital signs,
vision, height, weight, Body Mass Index (BMI)) shall be completed at the
initial CPA and at the time of the focused note.
(6) The first Medical Grade is assigned at the time of
the first CPA. The Medical Grade is to be updated or changed whenever the
youth's health status changes to such an extent that it is warranted.
(7) Registered Nurses and Licensed Practical
Nurses may only increase a Medical Grade; they are not permitted to decrease
grades. These changes shall be documented in the progress notes as well as the
Problem List (HS 026), Medication Administration Record (HS 019) and
Practitioner's Orders. The Problem List (HS 026, April 2024) is incorporated
into this rule and is available electronically at
http://www.flrules.org/Gateway/reference.asp?No=Ref-17502.
(8) For youth with a Medical Grade 1, the
Comprehensive Physical Assessment is current if performed within the last two
years. For Medical Grades 2-5, the Comprehensive Physical Assessment is current
if performed within the past 12 months.
(9) A Comprehensive Physical Assessment completed
prior to the youth's current admission may be used as follows:
(a) A current CPA with no changes in the youth's
medical condition. The current CPA shall be reviewed as the youth is examined
and signed off as reviewed by the physician, PA, or APRN.
(b) The CPA shall only be reviewed with the completion
of a focused note, up to six times, before a new CPA shall be initiated to
avoid confusion on the youth's condition and to ensure clear documentation of
the current condition.
(10) The facility director or superintendent or their
designee must ensure that all youth receive a CPA within the above-defined
timeframes.
(11) A visual acuity
(without correction) of 20/40 (both eyes) will require referral for visual
examination by a licensed optometrist or ophthalmologist within 60 days of
screening.
(12) A BMI of less than
18 or greater than 29.9, shall have a periodic evaluation and initiate a plan
of care by the DHA/designee. After the DHA completes the physical assessment,
the DHA may document justification if a plan of care is not needed for obesity
(i.e., large muscle mass).
Notes
Rulemaking Authority 985.64(2) FS. Law Implemented 985.64(2), 985.145, 985.18 FS.
New 3-16-14.
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