Florida Regulations 63M-2.0048: Comprehensive Physical Assessment (CPA)
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(1) The Comprehensive Physical Assessment (HS 007) shall be completed no later than seven (7) calendar days following the date of admission and prior to the youth engaging in strenuous exercise or being subjected to extreme outdoor weather conditions including, but not limited to, high heat indices and frigid temperatures. For youth with a Comprehensive Physical Assessment completed prior to admission, see subsection 63M-2.0048(8), F.A.C.
(2) 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.
(3) The standard Comprehensive Physical Assessment (CPA) form shall be used by all practitioners. The Comprehensive Physical Assessment (HS 007, October 2007) is incorporated into this rule and is available electronically at http://www.flrules.org/Gateway/reference.asp?No=Ref-03803, or may be obtained by contacting: DJJ, Office of Health Services, 2737 Centerview Drive, Tallahassee, FL 32399. When a community practitioner completes the CPA, (physician, PA, or ARNP), 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 ARNP shall augment that assessment to ensure that all of the CPA’s required components are clearly documented on the alternate form.
(4) 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.
(5) 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.
(6) 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, October 2006) is incorporated into this rule and is available electronically at http://www.flrules.org/Gateway/reference.asp?No=Ref-03804, or may be obtained by contacting: DJJ, Office of Health Services, 2737 Centerview Drive, Tallahassee, FL 32399.
(7) 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.
(8) 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 ARNP.
(b) A current CPA with a change in the youth’s medical condition. The clinician shall conduct a focused medical evaluation of the youth and document in the progress notes of the Individual Health Care Record.
(9) The facility director or superintendent or their designee must ensure that all youth receive a CPA within the above-defined timeframes.
Rulemaking Authority Florida Statutes § 985.64(2). Law Implemented 985.64(2), 985.145, 985.18 FS. History-New 3-16-14.
(3) The standard Comprehensive Physical Assessment (CPA) form shall be used by all practitioners. The Comprehensive Physical Assessment (HS 007, October 2007) is incorporated into this rule and is available electronically at http://www.flrules.org/Gateway/reference.asp?No=Ref-03803, or may be obtained by contacting: DJJ, Office of Health Services, 2737 Centerview Drive, Tallahassee, FL 32399. When a community practitioner completes the CPA, (physician, PA, or ARNP), 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 ARNP shall augment that assessment to ensure that all of the CPA’s required components are clearly documented on the alternate form.
(4) 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.
(5) 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.
(6) 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, October 2006) is incorporated into this rule and is available electronically at http://www.flrules.org/Gateway/reference.asp?No=Ref-03804, or may be obtained by contacting: DJJ, Office of Health Services, 2737 Centerview Drive, Tallahassee, FL 32399.
(7) 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.
(8) 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 ARNP.
(b) A current CPA with a change in the youth’s medical condition. The clinician shall conduct a focused medical evaluation of the youth and document in the progress notes of the Individual Health Care Record.
(9) The facility director or superintendent or their designee must ensure that all youth receive a CPA within the above-defined timeframes.
Rulemaking Authority Florida Statutes § 985.64(2). Law Implemented 985.64(2), 985.145, 985.18 FS. History-New 3-16-14.