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5.03 – History and Physical


The attached format will be used for ICF History and Physicals for all individuals.

Admission Requirements

Upon admission, the nursing staff will be responsible or evaluating and assessing the individual thoroughly in order to:

  • Complete physical body systems assessment by admitting nurse
  • Initiate Nursing Care plan within 72 hours of admission
  • Implement physician orders including obtaining proper medication clarifications, communication with pharmacy regarding needs, and ensuring all orders are initiated
  • Communicate with Medical Director
  • A complete History and Physical must be completed by the Medical Director within 30 days of admission.

A complete History and Physical must be completed by the Medical Director annually.  Any concerns identified will be communicated to the IPP team. 

The Nursing department is responsible to schedule the Physical, file the physical form and complete any needed follow-up.


Before admission, a copy of History and Physical form must be provided as part of individual’s collateral.  If one is not provided, the Habilitation Coordinator must ensure that a full History and Physical is completed by licensed physician within 30 days of admission.

A full History and Physical must be completed by a physician annually. 

Tracking of Annual Physicals will be maintained by the Habilitation Coordinator using the Advisor software.  Annual physical renewals will be communicated to team the month prior to ensure that updates are completed timely.  A copy of Physical form will be maintained in file at office.

Refer to attachment for History and Physical form.

Last Revised: 6/6/22

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