nursing home visit template

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A Nursing Visit Report Form is a document made when the nurse visited the patient at home or at the nursing home. The nurse assesses the medical status of the patient by taking the vital signs and reviewing the body systems which includes the sensory, musculoskeletal, integumentary, neurovascular, circulatory, respiratory, dental, psychosocial, nutrition, and elimination. This report also identifies the problems of the patient and the interventions that we can advise.

This remarkable Nursing Visit Report Form Template shows the patient information, health assessment data, review of systems, problem analysis, review of systems, and the registered nurse details. This PDF template is using the Input Table to show the vital signs and review of systems in a format table. In order to have the checkbox and textbox in the same row, the Input Table uses the multiple type columns option. This template also uses the Configurable List widget where the user can dynamically add fields as needed.

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Nursing Home Visit

Description

A nursing home visit is a family- nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing  home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes.

• To give care to the sick, to a postpartum mother and her newborn with the view teach a responsible family member to give the subsequent care.
• To assess the living condition of the patient and his family and their health  practices in order to provide the appropriate health teaching.
• To give health teachings regarding the prevention and control of diseases.
• To establish close relationship between the health agencies and the public for the promotion of health.
• To make use of the inter-referral system and to promote the utilization of community services

The following principles are involved when performing a home visit:

• A home visit must have a purpose or objective.
• Planning for a home visit should make use of all available information about the patient and his family through family records.
• In planning for a home visit, we should consider and give priority to the essential needs if the individual and his family.
• Planning and delivery of care should involve the individual and family.
• The plan should be flexible.

The following guidelines are to be considered regarding the frequency of home visits:

• The physical needs psychological needs and educational needs of the individual and family.
• The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
• The policy of a specific agency and the emphasis given towards their health programs.
• Take into account other health agencies and the number of health personnel already involved in the care of a specific family.
• Careful evaluation of past services given to the family and how the family avails of the nursing services.
• The ability of the patient and his family to recognize their own needs, their knowledge of available resources and their ability to make use of their resources for their benefits.
• Greet the patient and introduce yourself.
• State the purpose of the visit
• Observe the patient and determine the health needs.
• Put the bag in a convenient place and then proceed to perform the bag technique .
• Perform the nursing care needed and give health teachings.
• Record all important date, observation and care rendered.
• Make appointment for a return visit.
• Bag Technique
• Primary Health Care in the Philippines

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Nursing Home Admission Checklist

Learn the ins and outs of this comprehensive tool and guide for effective and well-informed transitioning into a nursing home setting.

By Harriet Murray on Apr 08, 2024.

Fact Checked by Ericka Pingol.

What is a Nursing Home Admission Checklist?

A Nursing Home Admissions Checklist is a comprehensive tool used by individuals, families, and healthcare professionals to ensure a smooth and well-informed transition when admitting a loved one or a patient to a nursing home facility. This checklist serves as a guide, detailing essential factors and considerations that need attention before, during, and after admission. 

Nursing home admission checklists typically cover a wide range of crucial aspects, including medical, social, financial, and emotional considerations. For instance, it may include items such as medical history documentation, medication management, personal care needs assessment, insurance coverage verification, legal paperwork review, and discussions about the resident's preferences and expectations.

The checklist offers several valuable benefits in the nursing home admission process. Firstly, it is a comprehensive framework that helps individuals and families organize and gather necessary documents and information. It ensures xdno critical details are overlooked, facilitating a smoother and more efficient admission process. Instigating the use of this checklist promotes informed decision-making. 

By outlining various aspects to consider, such as medical needs, facility amenities, staff-to-resident ratios, and available services. The checklist assists in evaluating different nursing home options, which in turn aids families and caregivers in choosing a facility that best aligns with the resident's needs and preferences.

The checklist fosters communication and collaboration among healthcare professionals, families, and the nursing home staff. It encourages discussions about the resident's care plan, expectations, and any specific requirements, ensuring that everyone involved is on the same page regarding the resident's care and well-being. 

This checklist also serves as a reference tool beyond the admission phase. It remains a valuable resource for ongoing care planning, helping families and staff stay organized and attentive to the resident's evolving needs throughout their stay in the nursing home.

Printable Nursing Home Admission Checklist

Download this Nursing Home Admission Checklist to ensure a smooth and well-informed transition when admitting a patient to a nursing home facility.

How does it work?

The admissions process for a nursing home can be lengthy and requires thorough detail to ensure all aspects of care are discussed and can be met by both the facility and the individual. Below are the steps involved to create a viable Nursing Home Admissions Checklist:

Step one: Gather your resources

Admissions checklists for nursing homes are a valuable resource and essential to keep on hand. Make sure that you have a copy of the free printable PDF when the need arises by either clicking the “Download Template” or “Use Template” button or by searching “Nursing home Admissions Checklist” on Carepatron’s template librar y ’s search bar on the website or app.

Step two: Gather information

Begin by collecting information about the resident/patient. This includes their medical history, current medications, care needs, preferences, and any legal or financial documents relevant to their care.

Step three: Identify key categories

Outline the different categories or sections that need consideration in the checklist. This often includes medical information, personal care needs, legal and financial aspects, facility amenities, and resident preferences.

Step four: Consult resources

Utilize resources such as nursing home admission guidelines, healthcare facility checklists, and regulatory requirements to ensure the checklist encompasses all essential areas.

Step five: Medical assessment

Include items related to the resident's medical needs. This involves details about medical conditions, allergies, required medications, and any treatments or therapies the resident requires.

Step six: Personal care needs

Document the resident's daily living requirements, such as bathing, dressing, mobility assistance, dietary needs, and any specific care instructions.

Step seven: Legal and financial documentation

Include a section for legal paperwork, insurance coverage verification, financial considerations, and advance directives, ensuring all necessary legal documents are in place.

Step eight: Facility assessment

Evaluate the nursing home facility against specific criteria. Consider factors like staff-to-resident ratio, available services (rehabilitation, social activities), safety measures, cleanliness, and overall quality of care

Step nine: Resident preferences

Incorporate questions or items that inquire about the resident's preferences regarding activities, meal choices, social interactions, religious considerations, and any specific requests they might have.

Step ten: Review and revision

After creating a draft, review the checklist to ensure it covers all necessary aspects. Seek input from healthcare professionals, family members, and the nursing home staff to refine and enhance the checklist.

Step eleven: Finalize and distribute

Once the checklist is comprehensive and inclusive, finalize the document. Share copies with involved parties, including family members, healthcare providers, and the nursing home staff, to ensure everyone is informed and prepared.

Nursing Home Admission Checklist example (sample)

Discover our Nursing Home Admission Checklist PDF for a comprehensive guide to assessing and enhancing senior living spaces and the care provided. This downloadable example covers care requirements, personal preferences, and assurance factors for maintaining quality of life. 

Utilize this checklist to help with the admissions process or to begin conversations around wants and needs within the nursing home setting. Access a pre-filled PDF example below for future confident use of the resource. 

Download this Nursing Home Admission Checklist example: 

When would you use this template?

Nursing home admission checklists are used at various stages of the admissions process:

Pre-admission planning

Families and healthcare professionals use these checklists when considering different nursing home options during the initial planning phase. They help evaluate facilities, assess their services, and compare them based on the resident's specific needs.

Admission procedures

When the decision is made to admit a loved one or patient to a nursing home, the checklist guides the gathering of essential documents, medical information, legal paperwork, and personal preferences needed for admission.

Facility tours and evaluations

During visits to potential nursing homes, the checklist is a reference tool to assess the facility's amenities, staff-to-resident ratio, safety measures, and overall suitability for the resident's needs.

Communication and coordination

Healthcare professionals, families, and nursing home staff use the checklist to communicate effectively. It ensures that everyone involved is aware of the resident's medical history, care needs, preferences, and any specific requirements.

Ongoing care pllanning

Even after admission, the checklist remains valuable for ongoing care planning. It serves as a reference to ensure the resident's evolving needs, preferences, and care plans are continuously reviewed and updated.

Regulatory compliance

Nursing homes may use standardized admission checklists to ensure compliance with regulatory requirements and to maintain documentation of the admission process for legal and regulatory purposes.

What do the results mean?

The results of a nursing home admissions checklist offer a comprehensive overview and assessment of various critical factors related to the admission process. They represent a thorough evaluation of the nursing home facility, the resident's needs, and the alignment between the two. These results hold significant implications for the well-being and quality of care provided to the residents entering the facility.

The checklist results signify the suitability of the nursing home facility for accommodating the resident's specific needs. They encompass an evaluation of the facility's amenities, staff capabilities, safety measures, available services, and overall environment. 

Positive results indicate that the facility meets or exceeds the necessary standards to provide adequate care and support tailored to the resident's requirements. These results also serve as a snapshot of the facility's adherence to regulatory and quality standards. 

A thorough checklist assessment ensures that the facility complies with legal and regulatory requirements, ensuring that the resident's rights are protected and that the facility operates within established safety, care, and services guidelines.

Additionally, the results of the checklist provide insights into the resident's individual needs and preferences. They document specific care requirements, medical history, dietary needs, mobility assistance, personal care preferences, and other crucial aspects. This information is vital for the nursing home staff to create a personalized care plan that addresses the resident's unique needs, ensuring a comfortable and supportive environment.

The results of this particular checklist facilitate informed decision-making for families and healthcare professionals. They help in choosing the most suitable nursing home that aligns with the resident's needs, preferences, and overall well-being. Positive checklist results can reassure families, indicating that the chosen facility can provide the necessary level of care and support.

These results serve as a starting point for ongoing care planning within the facility. They form the basis for developing a comprehensive care plan that adapts to the resident's evolving needs, ensuring that the care provided remains tailored and effective throughout their stay.

Why use Carepatron as your  Nursing Home Admission Checklist app?

Carepatron stands out as a comprehensive Nursing Home Admission Checklist app due to its user-friendly interface and multifaceted functionalities. Its intuitive design simplifies the admission process by providing a structured framework to gather and organize essential information seamlessly. The app's versatility accommodates various aspects of nursing home admission, including clinical documentation , personal care needs assessment, legal paperwork review, and facility evaluation.

One of its significant advantages lies in its adaptability to individual needs. Carepatron allows customization to tailor the checklist according to specific requirements, ensuring that every aspect relevant to the resident's admission is covered. This flexibility ensures a personalized checklist that aligns precisely with the resident's unique needs and preferences.

Carepatron is a centralized platform for collaboration and communication among family members, healthcare professionals, and nursing home staff. It facilitates streamlined communication by allowing multiple stakeholders to access and update the checklist in real time through patient portal software . This fosters transparency and ensures that everyone involved is well-informed and on the same page regarding the resident's care needs and preferences.

Carepatron's adherence to security and privacy standards ensures the confidentiality of sensitive information. The app's robust security measures comply with global security requirements, including HIPAA, GDPR, and HITRUST. Safeguarding personal and medical data is paramount to Carepatron and helps instill trust and confidence in users regarding protecting their information.

Butcher, H. K., Holkup, P. A., Park, M., & Maas, M. (2001). Thematic analysis of the experience of making a decision to place a family member with Alzheimer’s disease in a special care unit. Research in Nursing & Health, 24(6), 470–480. https://doi.org/10.1002/nur.10005 

Chenier, M. C. (1997). Review and analysis of caregiver burden and nursing home placement. Geriatric Nursing, 18(3), 121–126. https://doi.org/10.1016/s0197-4572(97)90029-x 

Gaugler, J. E., Kane, R. L., Kane, R. A., & Newcomer, R. (2005). Early Community-Based Service Utilization and Its Effects on Institutionalization in Dementia Caregiving. The Gerontologist, 45(2), 177–185. https://doi.org/10.1093/geront/45.2.177 

Harboun, M., Dorenlot, P., Cohen, N., Steinhagen-Thiessen, E., & Ankri, J. (2008). Impact of hip fracture, heart failure and weight loss on the risk of institutionalization of community-dwelling patients with dementia. International Journal of Geriatric Psychiatry, 23(12), 1245–1252. https://doi.org/10.1002/gps.2058

Ryan, A. A., & Scullion, H. F. (2000). Nursing home placement: an exploration of the experiences of family carers. Journal of Advanced Nursing, 32(5), 1187–1195. https://doi.org/10.1046/j.1365-2648.2000.01589.x 

World Health Organization. (2022, October 1). Ageing and Health. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health 

Yaffe, K. (2002). Patient and Caregiver Characteristics and Nursing Home Placement in Patients With Dementia. JAMA, 287(16), 2090. https://doi.org/10.1001/jama.287.16.2090

Commonly asked questions

To create a comprehensive Nursing Home Admission Checklist, simply utilize the checklist provided by Crepatron and identify priorities for you and your loved ones from the list that resonate with the kind of care you are seeking. 

This multi-use tool may come in handy while looking for a nursing home or deciding whether a patient needs to seek nursing home-level care. 

These checklists are used in many ways, whether for nursing home hunting, assessment of care needs, or to act as a discussion point of care priorities between loved ones and the patient. 

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Nursing Home Physician Visit

Schedule visit with resident, review resident's medical records.

• 1 Check allergies
• 2 Review previous treatments
• 3 Note any relevant medical history

Preparation of necessary paperwork

• 1 Consent forms
• 2 Assessment forms
• 3 Other required documentation

Inform the nursing staff of the visit

Pack necessary equipment and medical supplies.

• 1 Stethoscope
• 2 Blood pressure cuff
• 3 Thermometer

Travel to the nursing home

• 1 Nursing Home A
• 2 Nursing Home B
• 3 Nursing Home C

Check in at the nursing home front desk

Meet the resident and nursing staff, perform physical examination.

• 1 Heart and lungs
• 3 Extremities
• 5 Neurological functions

Discuss examination findings with resident

Approval: examination findings.

• Perform physical examination Will be submitted

Provide medical advice and treatment plans

• 1 Medication
• 2 Physical therapy
• 3 Dietary changes
• 4 Home care
• 5 Referral to specialist

Update medical records with visit information

Discuss care plan with nursing staff, create a follow-up plan, prepare notes and recommendations for staff.

• 1 Medication changes
• 2 Lifestyle modifications
• 3 Further tests or evaluations
• 4 Referral to specialist
• 5 Follow-up appointments

Approval: Follow-Up Plan

• Create a follow-up plan Will be submitted

Pack up equipment and medical supplies

Check out at the nursing home front desk, travel back to office or home base, take control of your workflows today., more templates like this.

Lumiform / Checklists / Streamline patient care with a social worker home visit checklist

Streamline patient care with a social worker home visit checklist

• What is a social worker home visit checklist?

Social worker home visit checklists enforce guidelines that ensure client health is assessed in a thorough, consistent, and professional manner . In order for a home visit to be effective, the checklist you used needs to cover all the guidelines for social workers, including:

• The client’s living space
• The household members’ health
• The household members’ habits (eating and sleeping)
• The household member’s leisure time activities

An incorrect assessment may wind up damaging the patient’s overall wellbeing. This is why many healthcare facilities use a standardized social worker home visit checklist, because it’s a step-by-step walkthrough that ensures patient safety and living conditions are evaluated correctly.

Table of contents

Why use a social worker home visit checklist, 1. check for unsafe or unhealthy conditions, 2. look for physical hazards, 3. note family members in the home, 4. take lots of pictures, 5. observe mental health signs, 6. find out if they’re getting enough support from family and friends.

Home visit safety checklists for social workers are a means of identifying hazards present in a client’s living situation. During a home visit, social workers document every detail included in these checklists , leading to the most objective and accurate assessment possible.

These checklists are necessary because they gather all relevant information in one place so that clients get the best service possible. A social worker home visit checklist will make sure that all potential issues are identified before going into a client’s house, so that when something goes wrong, you’re prepared to address it.

What should a social worker home visit checklist include?

Social services workers are often the first point of contact for people who are experiencing a crisis . A social work home visit checklist can be used to determine whether or not a patient is ready to return to work, or by a judge who is deciding whether or not someone can be granted custody of their child.

They are responsible for ensuring that the people they serve have access to the help they need, and for making sure that clients are as comfortable as possible during social work visits.

Given those responsibilities, a social worker home visit checklist needs to:

• Check for unsafe or unhealthy conditions
• Look for physical hazards
• Note family members in the home
• Include pictures of the household
• Document signs of poor mental health
• Check for social support from family and friends

How do you write a social worker home visit checklist?

Pest infestations, rodent infestations, cockroach infestations, bed bugs, fleas, and lice are some of the most common health hazards that you may encounter during a home visit investigation.

Check for signs of these pests inside and outside the home. If you find any evidence of these conditions, your client may require assistance getting rid of them or changing their living situation.

A home visit safety checklist for social workers should include the following:

• The client’s home is free from pests, rodents, cockroaches and other insect infestation.
• The client’s home environment is not exposed to extreme weather conditions that can breed insect infestation.
• The client is living in premises that are free from pests.

Look for trip hazards, fall hazards, sharp edges on furniture, and any other items that could injure children. Make sure nothing in the home poses an electrical hazard. Check for frayed or poorly placed cords (such as those near a table leg or child’s toy).

Look for anything that has exposed wires or hot surfaces. Inspect all outlets and light switches and make sure they are not tampered with in any way.

During home visits, social workers should make sure:

• No harmful exposure to clients’ health is observed, such as household products with hazardous ingredients like ammonia, bleach, or paint thinner (all of which can cause poisoning)
• No issue needs to be reported to Child Welfare Services for further investigation
• Handrails are provided for the senior’s bathroom
• Furnishings and activities are age appropriate

The checklist should includes names of the client’s family members. It’s important to ask the family questions about their living situation, such as:

• Are there any new members?
• Has anything changed recently? (e.g., birth, death)
• Have there been any recent moves? (e.g., recently returned from evacuation center)

Taking pictures is a great way to document the condition of a home. It’s also important to take pictures of any food, clothing or toys that the patients use. For example, do you only see one pair of shoes for all three children? This could be a sign that someone in the family needs new shoes.

Taking photos also reminds you what you saw during your visit and gives you something tangible to show later on in court or in meetings with other professionals.

Take pictures of the backyard or outside area to document the condition of the home and provide evidence for your report.

Any photos you take should:

• Be well lit, in focus, and taken with a good quality camera (e.g., digital). Don’t use your smartphone’s camera.
• Have all relevant information in frame (e.g., both sides of the house; sidewalk leading up to the house).
• Include multiple versions for different times of day so that you can capture every possible view (e.g. to show how dark it gets in the front yard when streetlights turn off).

While a social worker home visit is mainly focused on the patient’s physical health, it’s important to check in on their mental health as well. Mental health problems can make a person feel isolated , which can lead to depression and even suicide.

If you notice that your patient is showing signs of depression, isolation, or any other signs of mental distress, make sure to speak with them about it. You may also propose therapy.

Some signs you as a social worker should look for include:

• Excessive sadness
• Feelings of worthlessness
• Difficulty concentrating and making decisions
• Sleep problems (insomnia or sleeping too much)
• Low energy and fatigue
• Irritability

A person’s support network is a vital aspect of a social worker home visit checklist. Informal carers provide important emotional and practical help for people with mental health problems, but are not always a support system as such. You can evaluate feelings of support by asking:

• Do you feel that your family/friends give you enough support?
• If not, what do they need to do more of?
• How often do you visit your family or friends every week?
• On a scale of 1 to 10, how happy are you with your social circles?

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Writing a social worker home visit checklist using workflow automation

Quality social worker home visit checklists are essential for social workers, especially when they’re new to the job. As a new social worker, it can be hard to know what information you’ll need and how much time you’ll have to devote to each task.

Paper-based checklists can be difficult to manage, especially if you’re dealing with multiple cases. That’s where workflow automation solutions like Lumiform come in. Lumiform makes creating checklists easy with a digital form builder, centralizes your staff, and synchronizes all their tasks so that they can work autonomously. Using Lumiform’s mobile app and desktop software allows you to:

• Turn all your manual data, records and images into digital forms that can be completed and viewed by any of your team members
• Make home visits faster, safer, and free of errors by recording even the smallest details automatically in regularly-generated analysis reports
• Help you and your social workers stay organized days or even weeks in advance with regular notifications and updates
• Create custom forms that are 100% tailor-made to suit your needs
• Complete your social work visits up to 10 times faster

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Max is a Content Writer at Lumiform originally from New York, NY. Before Lumiform, he worked at the fintech company, writing on a range of fintech-related topics. He has experience writing blogs, CRM communication, guides, and landing pages. In addition to a love of content writing, Max is passionate about standup comedy and cooking.

Care home audit maintenance and domestic

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Determine patient health with a home visit safety checklist

Use this template to assess the health status of a patient during a home visit.

Social Worker Home Visit Template

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A step-by-step approach that saves time coding E/M office visits can now be tailored to hospital and nursing home E/M visits as well.

KEITH W. MILLETTE, MD, FAAFP, RPh

Fam Pract Manag. 2023;30(1):8-12

Author disclosure: no relevant financial relationships.

Following the major revisions to coding evaluation and management (E/M) office visits in 2021, 1 a similar revamp has been made for coding E/M visits in other settings. Effective Jan. 1, 2023, the history and physical examination requirements have been eliminated for coding hospital and nursing home visits. 2 As with office visits, hospital and nursing home coding is now based solely on medical decision making (MDM) or total time (except for emergency department visits, which must be coded based on MDM, and hospital discharge visits, which must be coded based on time). This further streamlines E/M coding, creating one unified set of rules for office, nursing home, and hospital visits.

Hospital and nursing home E/M visits are divided into three groups: initial services (i.e., admissions), subsequent services, and discharge services. According to the American Medical Association (AMA), initial visits are “when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.” 2 After the patient has received care from that group once, all other visits are subsequent until the discharge service. When the patient transitions from inpatient to observation, or vice versa, that does not begin a new stay eligible for an initial services visit.

CPT codes 99234-99236 are for patients admitted to the hospital and discharged on the same date. For patients with multi-day stays, use 99221-99223 for initial services, 99231-99233 for subsequent visits, and 99238-99239 for discharge services.

Initial nursing home visits are coded with 99304-99306. CPT is deleting the code for nursing home annual exams (99318), which will instead be coded as subsequent nursing home visits (99307-99310).

Two sets of observation care codes (99217-99220 and 99224-99226) should no longer be used as of Jan. 1. Observation services have instead been merged into the corresponding initial service, subsequent service, and discharge codes.

These changes open the door to a simpler, quicker coding process. Many of the principles that already apply to E/M office visit coding now apply to hospital and nursing home E/M coding, but there are some differences in the details. This short guide can help physicians navigate the changes.

Coding for evaluation and management (E/M) visits in hospitals and nursing homes is now much like coding E/M office visits.

This unified set of coding rules allows physicians to quickly code nearly all visits using a template that starts with total time.

There are a few key differences to be aware of, such as total time spent past midnight on the date of service can be counted for hospital E/M visits, but not for office E/M visits.

MEDICAL DECISION MAKING

Determining the level of MDM for hospital and nursing home visits is now much like doing so for office visits. 3 The four MDM levels are straightforward, low, moderate, and high. They are determined by three factors: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the patient's risk of complications, morbidity, or mortality.

If you feel confident coding office visits based on MDM, you can use that knowledge to code hospital and nursing home visits based on MDM as follows:

A level 1 initial or subsequent hospital visit requires the same MDM components as a level 3 office visit,

A level 2 initial or subsequent hospital visit requires the same MDM components as a level 4 office visit,

A level 3 initial or subsequent hospital visit requires the same MDM components as a level 5 office visit.

Several medical decisions that are more common in hospitals than office settings carry enough risk that, when paired with high-level problems, they call for the top visit level. These include the decision to escalate hospital care (e.g., transfer to the intensive care unit), the decision to deescalate care or discuss do-not-resuscitate orders due to poor prognosis, the decision to use IV narcotics or other drugs that require intensive monitoring, and decisions regarding emergency surgery for patients with or without risk factors or non-emergency surgery for patients with risk factors.

There are new time thresholds for each level of service for initial hospital visits, subsequent hospital visits, and nursing home visits to use when you are coding by total time. Instead of offering a time range like office visits (e.g., a 99214 office visit requires 30–39 minutes), nursing home and hospital care visits require that you meet or exceed specific times (e.g., a 99232 subsequent hospital visit requires 35 or more minutes).

When coding initial hospital visits by total time, you can count all the time you spend caring for the patient on admission even if some of it extends after midnight on the calendar day of the admission. According to the AMA, “a continuous service that spans the transition of two calendar dates is a single service and is reported on one calendar date. If the service is continuous before and through midnight, all the time may be applied to the reported date of service.” 3 This differs from office visits, for which you may count only the time on the date of the visit. Otherwise, the definition of total time for hospital and nursing home E/M visits is similar to that of office visits. It includes the time you personally spend on E/M for that patient before, during, and after the face-to-face services. It does not include staff time, time spent on separately reportable procedures, travel time, or teaching time.

A SIMPLER WAY TO CODE

Like the 2021 changes to office visit E/M coding, the 2023 changes should make coding hospital and nursing home E/M visits simpler and quicker.

The universal coding template suggests coding by time first if that will appropriately credit you for the work you did. It's the most straightforward and easy method. But if you believe MDM will credit you for a higher level of work, then step 2 is to determine what level of problems (low, moderate, or high) you addressed and whether you managed (prescribed, adjusted, or decided to keep the same) a prescription medication. Answering those two questions allows you to code most visits quickly using MDM. For the few visits that remain, you will need to proceed to steps 3 or 4, which may require you to tally data points and are therefore more time-consuming.

The template was adapted from a prior FPM article on office E/M coding 4 by adding nursing home and hospital visit times and relabeling office-visit level 3, 4, and 5 problems as low-, moderate-, and high-level problems.

UNIVERSAL CODING TEMPLATE

Step 3: MDM with simple data

Moderate-level problem PLUS one of the following:

• Interpret one study (e.g., “I personally looked at the x-ray, and it shows …”),
• Discuss patient management or a study with an external physician (one who is not in the same group practice as you or is in a different specialty or subspecialty),
• Modify workup or treatment because of social determinants of health.

EQUALS moderate-level visit, even without medication management (see codes in Step 2).

Step 4: MDM counting data points

Moderate-level problem PLUS at least three points from data counting (below),

EQUALS moderate-level visit (see codes in Step 2).

High-level problem PLUS at least two of these three:

• Interpret one study (e.g., "I personally looked at the x-ray, and it shows..."),
• Discuss patient management or a study with an external physician,
• At least three points from data counting (below),

EQUALS high-level visit (see codes in Step 2).

Data counting:

• Review/order unique test/study: 1 point for each,
• Review external notes: 1 point for each unique source,
• Assessment requiring use of an independent historian (family member or other person who can provide a reliable history for a patient who is unable to): 1 point max.

Documentation to support your coding should also be easier going forward. While documenting a medically appropriate history and physical exam is still certainly important for good patient care, it's no longer required for coding; therefore, you should be able to determine the code level from only a few lines of documentation. The quiz below provides some examples to pair with the coding template for practice.

Hopefully, using this step-by-step approach to the 2023 E/M coding changes will allow you to code many types of visits more quickly and accurately so you can spend more time with your patients and less time on the computer.

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

CPT evaluation and management (E/M) code and guideline changes. American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Table 2 - CPT E/M office revisions level of medical decision making (MDM). American Medical Association. Accessed Nov. 2, 2022. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Millette KW. A step-by-step time-saving approach to coding office visits. Fam Pract Manag . 2021;28(4):21-26.

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1350 Troy Highway Moscow , ID 83843 United States

Moscow vs St. Petersburg – Which One to Visit?

• Posted on July 31, 2019 August 3, 2019
• by Kings of Russia
• 8 minute read

When it comes to Russian girls and Eastern Europe generally, guys love to debate over which city has the hotter girls – Moscow vs St. Petersburg.

Some say they’re all the same; others say there are clear differences, while some locals will laugh then explain in autistic detail just how different every district of each city is but it doesn’t matter because you’re a foreigner and all you have to do is show your passport.

Doing comparisons can be difficult because at the heart of the matter; all cities share a similar energy that is transferrable from one country to the next. Cities all over the world attract a specific kind of mentality: those seeking careers, adventure, and anonymity. Yet certain cities seem to excel in certain things relative to others, which end up attracting certain kinds of girls. From the many cities I’ve traveled to, I can always distill the essence of the place to two overarching mindsets: business and culture.

For our purposes here we’ll be talking about Saint Petersburg and Moscow. Combined, their metro population is about 23 million, which is about 15% of the entire Russian Federation despite being clustered in a small part of Eastern Europe. In other words, it’s a very dense area.

Similarities between Moscow and St. Petersburg

Both cities attract girls from all over Russia , and also the former Soviet countries as well as parts of Eastern and Central Europe. We are talking full on megalopolises here. Both are based off the center, from which everything then sprawls out. Both have efficient transportation systems that make getting around the sprawl quite easy. Both attract lots of students and career-oriented girls. Both cities attract scammers yet in different ways. Both cities are exotic yet familiar to Westerners.

Some people freak out about “going to Russia” because the lying media claim it’s dangerous and you’ll be robbed. Pay no attention to them. These same scaremongers have been saying the same thing for 100 years, all while creating danger and crime in the West and promoting chaos outside their borders.

Keep in mind that Saint Petersburg was built with Westerners in mind and Moscow has so much money floating around that unless you’re hanging out in an Uzbekistani’s car in the boondocks 15 miles out, you’ll generally be safer than in New York or London.

You’re likely to meet girls from the surrounding regions and provinces of both Saint Petersburg and Moscow. This can give Saint Petersburg a slant towards a “Northern” local population while Moscow has a “Central” pull. It’s also possible to meet girls from Kazakhstan, Siberia and Ukraine quite easily as well and girls from one region who prefer the atmosphere in the other, say a Northerner who’s into finance, or a Southerner obsessed with poetry.

Girls in both cities are friendly, but don’t mistake that for easiness. Russian girls know their value and you’ll have to put in the time and work to get them to open up. A particular girl may really like you and the “3 date rule” may not apply, or a girl may be slutty for her local guys but see you as a possible resource (shiny foreigner), hence may make you wait. Expect dating to be more normal than one night stands, unless the girl is completely westernized with tattoos, strange hair and strange piercings.

Differences

Now the biggest difference between Moscow and Saint Petersburg is that of mentality. And this mentality permeates into the girl’s aesthetic. In general, Saint Petersburg attracts the more creative, alternative, hipster crowd while Moscow brings in the more businesslike, refined, upscale one. You can find classical looking practical girls in Saint Petersburg and green-haired drug-abusing ones in Moscow but in general these two cities have their distinct template aesthetic. In St. Petersburg I’d more often than not ask myself “What is she doing looking like that?” whereas Moscow I’d just focus on the girl herself.  This doesn’t mean the girls in Saint Petersburg are genetically ugly; merely the appearance decisions they make is more in line with fully Westernized cities.

Like Paris vs London or New York vs Boston, Moscow and Saint Petersburg have a rivalry. There’s more money flowing into Moscow than Saint Petersburg, yet more cultural capital going through Saint Petersburg. This may account for why girls want to look like a “work of art” in Saint Petersburg while Moscow girls don’t seem to care as much.

Muscovites don’t necessarily dress fantastically either though. The hiptsterization has spread there and you can see some pretty uninspired fashion. Luckily the city is big and competitive enough so you don’t need to pay attention to the hipsters.

While all Russian girls like to talk about philosophical, literary and artistic things, I’ve found Muscovites to be more practical and interested in talking business, career, ambition and such. As a man, it’s your job to steer the conversation in the direction you want, just be aware of the overarching mentality you’ll find relative to which city you’re in.

Now if a girl is indirectly inquiring into your resources from a standpoint of being a long-term provider and you’re looking for a long-term relationship, it’s up to you to gauge the situation. Just be careful about exuding the idea of foreign wealth. Just because you can provide, does not mean you don’t deserve to be loved for who you are. Do not get taken in by superficial beauty as the consequences can burn later.

Defining Sexy

Defining what makes a girl sexy is another hotly debated topic. I know guys who have clear preferences on Moscow vs Saint Petersburg. Some like Saint Petersburg because it’s “easier”, others like Moscow because the girls are “hotter”. Others say Saint Petersburg girls are nicer, while Muscovites are too conniving and cold. Since we’re dealing with so many experiences, variables and populations I can only nudge you in the direction you think will help your situation and tastes.

If your definition of sexy is alternative, Western looking mentality, cultured and unusual dress but not necessarily unattractive underneath, Saint Petersburg may be the place for you.

If your definition of sexy is dressed to the nines, long hair, hip sway while walking and a go-getting work hard play hard attitude, then the Moscow girl sounds more like your bet.

Moscow carries a more distinct Russianness than Saint Petersburg and you’ll feel you’re in a more exotic place, though still with 1 st world style amenities. Some guys hate how the city is sprawled out, others marvel in its splendor. The girls here can be friendly but deceitful. Flaking is epidemic. In that sense it’s a lot like London or New York. There’s so much distraction and commotion it’s hard to find ground sometimes.

More guys seem to prefer Saint Petersburg as its Russia without the Russianness. Europeans and Americans alike enjoy the familiarity mixed with a touch of exoticness. The girls are easy going and friendly, and since their passion is towards arts and culture, they have a more liberal and relaxed attitude. For such a large city you don’t feel they’re stressed in the same way financial centers are.

Cautionary Tales on Scammers

Regarding scammers: in Saint Petersburg, bless their hearts, they have scamming down to a perfectly technical science. It’s not as obvious as a stripper with a hot pink umbrella and tickets telling you to come to the bar. These girls will match you on a dating app, have a perfectly normal conversation, even go with you to a venue one, and then perform the bait and switch by the time you feel buzzed and comfortable.

This bait and switch usually involves going to a bar she works with, has you sit down with her, and then proceeds to order an absurdly overpriced drink for which she gets a cut. As long as you do not agree to the terms well before it gets thrown on you, nothing will happen. Do not follow her into a venue, no matter how much she insists. There may be a small chance she’ll want to show you some cool dive bar, but you can easily verify this with Google reviews.

It’s not just from dating apps, both in my and friend’s experience, girls will give you huge IOIs on the street or in the mall, flirt with you heavily and fast forward to venue two and you realize the bait and switch with the overpriced champagne.

While Russian girls are friendly, put your ego aside and think for a minute. Why is she falling head over heels for you? Is she that desperate? Are you her perfect match? Or is she trying to get one up on you? Stay dispassionate and screen for her intent if it sounds too good to be true.

Some girls may not be official scammers but they get a kick out of racking up a huge bill. She’ll pout and whine that you don’t like her if you don’t give her what she wants. I find it so infantile that I usually end up walking out right then and there. You can try and laugh it off and game on, but be very careful around that kind of girl.

In Moscow, I’d say the girls are more businesslike and up-front in their scamming. You can feel it coming a mile away. They want to go to the obviously overpriced venue. They’re dressed in a revealing but kind of strange way, “working sexy” instead of “girly sexy” may be a way to put it. Think of bartenders trying to maximize business, but with more dress than jeans.

They want the most expensive thing right away and will shame you for not opening your bank account for her in 5 minutes. The high end clubs will even hire these girls to officially flirt with you then get you to order ridiculously priced drinks. Of all the scams, this one can be the worst as you’re in a normal venue under the influence, yet they’re working behind the scenes with the staff to scam you.

Once you can see these scams coming, they become obvious as the algorithm unfolds. As long as you keep your wits about, have your ego in check and screen properly you should be mostly able to avoid these scams. As the old saying goes, you can’t cheat an honest man. Become honest by questioning a girl’s extreme forwardness mixed with demands. Don’t just fall for her beauty.

Since sexiness can be subjective and I’ve seen first-hand how different friends clearly prefer certain cities, all you have to do is ask yourself where do you feel more at home? Moscow and Saint Petersburg have distinct personalities, and its likely one clicks more with you than the other. It may not even be the girls.

Some guys prefer certain city layouts which end up giving them a better vibe to approach girls and have more positive experiences. Other guys don’t mind sticking it out in a depressive sh**hole in search of glory. Ultimately the subjectivity of sexiness depends on what a man is looking for: how much more of rabbit vs a wolf he is in terms of sexual strategy, and where his personality and interests nudge him towards.

Start meeting Russian women online with the best dating app for long-term relationships:  Russian Cupid .

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