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A medical practitioner may select MBS item 701 (brief), 703 (standard), 705 (long) or 707 (prolonged) to undertake a comprehensive medical assessment for a permanent resident of an aged care facility depending on the length of the consultation and complexity of the patient’s presentation.

A comprehensive medical assessment is a review of the resident, including assessment of the resident’s health and physical and psychological functioning.

Components of a comprehensive medical assessment

A comprehensive medical assessment must include a personal attendance by a medical practitioner. The components of the assessment include:

• information collection, including taking a patient history and undertaking or arranging examinations and investigations as required;
• making an overall assessment of the patient;
• recommending appropriate interventions;
• providing advice and information to the patient;
• keeping a record of the health assessment, and offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment; and
• providing a written summary of the outcomes of the assessment for the resident’s records and to inform the provision of care for the resident by the residential aged care facility and assist in the provision of medication management review services for the resident.

Medical practitioners may review and incorporate into the comprehensive medical assessment relevant assessments or information about the resident that is available from the residential aged care facility.

In undertaking the assessment the medical practitioner should consider the following, as appropriate to the resident:

• cardiovascular and respiratory systems, and other systems as indicated;
• physical causes of acute and chronic pain;
• an assessment of the resident’s:
• physical function, including activities of daily living;
• psychological function, including cognition and mood;
• oral health, nutrition status and dietary needs; and
• skin integrity.

The comprehensive medical assessment may also cover matters of particular relevance to the resident.
For example, an assessment of the following factors may be undertaken as relevant to the resident:

• hearing and vision;
• smoking and alcohol use;
• foot care;
• sleep; and
• incidents of falls.

Restrictions on providing a comprehensive medical assessment

A Medicare rebate is payable once within any twelve month period for each eligible patient.

The comprehensive medical assessment is not available to residents who are receiving respite care.

New residents, including veterans, are entitled to a comprehensive medical assessment on admission to a residential aged care facility, provided that they have not already had this assessment at another facility within the previous twelve months. Existing residents can have a comprehensive medical assessment at twelve month intervals, where it is required in the opinion of the resident’s medical practitioner.

A comprehensive medical assessment must be provided by a medical practitioner; including a general practitioner but not including a specialist or consultant physician. Ideally, this assessment should be provided by the resident’s usual GP.

A medical practitioner providing services on a facility-wide contract basis and/or a GP registered to provide services to residential aged care facilities as part of aged care panel arrangements may also provide comprehensive medical assessments for residents as part of their services.

The comprehensive medical assessment may be completed over one or more visits, provided all the components of the assessment are undertaken before the item is claimed. A Locum can conduct a comprehensive medical assessment provided the resident’s usual GP has delegated the provision of this service to the Locum. The resident’s usual GP should be given a copy of the written summary of the outcomes of the assessment.

Other Requirements

The medical practitioner undertaking a comprehensive medical assessment must ensure consent to the assessment has been given by the resident or a representative with an enduring power of attorney.

Comprehensive medical assessments are voluntary and the medical practitioner providing the assessment should make sure that the resident or representative has agreed to the assessment being undertaken.

Where the resident has an informal or family carer, the medical practitioner may find it useful to consider having the carer present for the assessment or for some of its components, with the resident’s consent. The carer can provide useful information on matters such as medication usage and compliance and psychological and physical function, including specific matters such as continence.

Guidelines and Resources

For more detailed information about MBS item descriptors and explanatory notes visit the Department of Health website at MBS Online.

For more information about MBS primary care items or to access a sample proforma for this health assessment visit the Department of Health website at the MBS Primary Care Items page or phone the Department of Human Services (Medicare) provider enquiry line on 132 150 or the patient enquiry line on 132 011.

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