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W512
W512 – Admission assessment - Type 1
OHIP Consultations and Visits Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A Type 1 admission assessment is a general assessment rendered to a patient on admission to a long-term care institution. This service applies to patients in chronic care hospitals, convalescent hospitals, nursing homes, homes for the aged, and designated chronic or convalescent care beds in hospitals, excluding patients in designated palliative care beds.
As defined on page , a general assessment requires:
• A full history, including a history of the presenting complaint, family medical history, past medical history, social history, and a functional inquiry into all body parts and systems.
• An examination of all body parts and systems (except for breast, genital or rectal examination where not medically indicated or refused), and may include a detailed examination of one or more parts or systems.
All insured services must be documented in the patient's medical record to establish the service was provided, is the service claimed, and was medically necessary.
The service must include a direct physical encounter with the patient, including taking a patient history and performing a physical examination, as per the specific elements of assessments.
Requires a full history, including history of the presenting complaint, family medical history, past medical history, social history, and a functional inquiry into all body parts and systems.
Requires an examination of all body parts and systems, except where not medically indicated or refused for breast, genital, or rectal examinations.
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