440 IAC 10-4-20 Medical history and physical examination

Sec. 20. (a) An OTP shall conduct a physical examination of each patient at the following times: (1) Prior to admission to an OTP. (2) Annually thereafter. (b) The OTP shall fully document the nature, extent, and results of the physical examination in the patient's record. (c) The physical examination shall be performed by either of the following: (1) A program physician. (2) An authorized health care professional. (d) The physical examination shall include at least the following: (1) A health history, including the following: (A) Surgeries. (B) Allergies. (C) Significant medical problems. (D) Review of current prescriptions and over-the-counter medications. (E) Personal and family history of alcohol, drug, psychiatric, and medical conditions and treatment. (2) A review of all major physical systems, including the following: (A) Neurological. (B) Respiratory. (C) Cardiac. (D) Gastrointestinal. (E) Endocrine. (F) Musculoskeletal. (G) Urogenital. (3) For women, the following: (A) The date of the last menstrual period. (B) Pregnancy history. (C) Current pregnancy status, including the following: (i) Breastfeeding. (ii) Current menses status. (iii) Childbearing status. (4) A pain evaluation using a standard pain scale. (5) Vital signs, including the following: (A) Temperature. (B) Pulse. (C) Respiration. (D) Blood pressure. (6) An exploration of symptoms of communicable disease, including the following: (A) Tuberculosis. (B) Hepatitis A, B, and C. (C) Sexually-transmitted diseases. (D) HIV and AIDS. (7) A tuberculosis skin test, such as the intradermal Purified Protein Derivative (PPD) test. (8) Screening for syphilis and, for positive screens, referral for further evaluation. (9) A complete blood count. (e) Documentation of the full medical examination, including the results of serology and other tests, shall be recorded in the patient medical record not later than fourteen (14) days following the patient's admission.