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Rehabilitation Prescription and Passport

By Travis Parker,2014-02-06 20:46
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Rehabilitation Prescription and Passportand

     Please place patient sticker here Merseyside & Cheshire

    Clinical Networks

Rehabilitation Prescription and Passport

    1. Rehabilitation Prescription

    Patient prefers to be called Current placement (hospital/ward) Date of injury Date of admission Consultant Primary Reason for admission: (tick all applicable)

    Crush Injury ? Musculoskeletal ? Head Injury ? Spinal ? Major Hemorrhage ? Burns ? Amputation ? Penetrating Injury ? Other (specify) ? Vascular ? Allergies

    st1 Language/Barriers to communication

    Occupation Religion

    Next of Kin: Name Relationship

    Address

    Tel no (home) work mobile GP

    Address Tel no Rehabilitation Coordinator (if applicable) Contact details

    The TARN minimum dataset (MUST BE COMPLETED WITHIN 48 HOURS OF ADMISSION) Rehabilitation prescription (completed or not required)

    If not required state reason: Yes ? No ? Not required ? Physical factors affecting activities or participation Yes ? No ? Not assessed ? Non-physical factors affecting activities or participation Yes ? No ? Not assessed ? Psychosocial factors affecting activities or participation Yes ? No ? Not assessed ? If not assessed/required state reasons

    Estimated ISS Score Confirmed ISS Score Date/time completed

Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

    Short Clinical Assessment

     Initial Short Clinical Assessment (enter date and initials) Assessment Review Review Does the patient have any of the following? Date Date Date

     (enter Yes (Y) / No (N) / Unknown (U))

     ; Neurological Conditions (new episode)

     ; Multiple Trauma (please specify)

     ; Burns

     ; Sepsis

     ; Multi organ failure

     ; Tracheostomy

     ; Endotracheal Tube/unable to self-vent on 35% O2

     ; Amputation

     ; Multiple co-morbidities

     ; Spinal cord injury ( state Asia Grade)

    If yes refer to specialist Physiotherapist

    Additional Comments:

    Does the patient require assessment for splinting? (enter Y/N) Is the patient awake and exhibiting any of the following? (enter Y/N)

     ; Any neurological condition

     ; Any cognitive impairment

     ; Any anxiety problems

     ; Any seating problems

     ; Reduced independence and self-care

     ; Impaired movement of limbs

    If yes refer to specialist PT or OT

    Additional Comments:

    Is the patient awake and have any of the following? (enter Y/N)

     ; Neurological condition (old or new)

     ; Head or neck surgery/trauma

     ; Tracheostomy with cuff down and speaking valve

     ; Tracheostomy with no speaking valve regarding

    swallowing/weaning at medics request

     ; ET intubation > 48 hours

     ; Desaturation following oral intake

     ; Coughing on oral intake/other signs of aspiration

     ; Known history of dysphagia

     ; Difficulty eating or drinking / Nil by mouth

    Communication

     ; Difficulty speaking, finding words or understanding what is said

     ; Change in ability to read/write not due to visual/physical problems

     ; Change in voice quality

     ; Unable to express needs

    If yes refer to specialist SALT

    Additional Comments:

    Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

     Initial Short Clinical Assessment (continued) (enter date and initials) Assessment Review Review Does the patient have any of the following? Date Date Date (enter Yes (Y) / No (N) / Unknown (U))

     ; Receiving artificial nutrition

     ; High risk on Trust nutritional screening tool (e.g. MUST)

    OR (if no nutritional screening tool being used)

     ; Obviously wasted or very thin (BMI <18.5)

     ; Unintentional weight loss (>5%) over 3-6 months

     ; Nil by mouth or poor intake for >5 days

     ; Requiring modified texture diet

     ; BMI > 40

    If yes refer to specialist Dietitian

    Additional Comments:

Pharmacy Assessment

    Has the patient an NG tube or PEG in place which is being considered for medicine administration?

    Is the patient on immunosuppressants or cytotoxic therapy? If yes refer to Pharmacist

    Non-physical Assessment (Enter Yes / No / Unknown)

    Does the patient seem agitated, restless or anxious

     If YES obtain: stress history from family/friends and pre admission medication details Does the patient seem

     ; Lethargic, reluctant to mobilise or withdrawn

    Is the patient experiencing

     ; Recurrent nightmares / trying to stay awake to avoid

    nightmares

     ; Intrusive memories of traumatic events or in-patient

    experiences e.g. delusional experiences or flashbacks

     ; New and recurrent anxiety or panic attacks

     ; Reluctance to talk about their illness / injuries

    If yes administer CAM-ICU/ initiate local protocols within NICE guidance/refer for psychology assessment Overall CAM-ICU Score ……….. (Features 1 and 2 must be positive and either 3 or 4 positive) If delirious and no precipitating causes, treat.

    If NOT delirious ascertain cause e.g. panic at weaning, and refer to MDT

    Additional comments:

    Does the patient suffer from substance dependency? (Enter Yes / No / Unknown)

    Additional Comments:

    Does the patient have any known mental health issues? (Enter Yes / No / Unknown)

    Additional comments:

Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

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     Merseyside & Cheshire

    Clinical Networks

Safeguarding factors

    Mental Capacity or Deprivation of Liberty issues

Power of Attorney or Court of Protection in place

Police or Solicitor contact information

Referral for Comprehensive Assessments

    Profession Referral Date Date first seen

Physiotherapy

OT

SALT

Dietetics

Pharmacy

Non-physical/Other

Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

    2. Rehabilitation Passport

    MDT Rehabilitation and Re-ablement Goals (to be agreed with patient) Location:

    Date Name and Date Problem List Goals Treatment Plan Achieved Profession

    Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

    2. Rehabilitation Passport

MDT Rehabilitation and Re-ablement Goals (to be agreed with patient) Location:

    Date Name and Date Problem List Goals Treatment Plan Achieved Profession

    Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

    Review for Comprehensive Assessments (as appropriate)

     Seen by Date Review Date

     Physiotherapy

     OT

     SALT

     Dietetics

     Pharmacy

     Non-physical

     Seen by Date Review Date

     Physiotherapy

     OT

     SALT

     Dietetics

     Pharmacy

     Non-physical

     Seen by Date Review Date

     Physiotherapy

     OT

     SALT

     Dietetics

     Pharmacy

     Non-physical

     Seen by Date Review Date

     Physiotherapy

     OT

     SALT

     Pharmacy

     Dietetics

     Non-physical

Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

    Functional Assessments

    1. Current Functional Status

    Neurological

     Vision

     Motor loss Sensory Loss Intact ? impaired ? unable to assess ? GCS…….. Yes ? No ? Yes ? No ? Hearing

    Intact ? impaired ? unable to assess ? Respiratory

     Type: Support

     If YES: is required on Assisted ventilation Yes ? No ? there a mgt Yes ? No discharge

    plan? ? Yes ? No ? Sitting Ability

    Transfers

     Standard chair Special With hoist/stand ? Unable to sit out ? Able to sit out ? ? seating ? Assistance ? No. people …..

    Independently ? Washing and Dressing: Independent ? Assistance ? No. people…… Continence

    Urinary Faecal Catheter in situ Yes ? No ?

    Uses toilet/commode/urinal Uses toilet/commode independently Yes ? No ? independently Yes ? No

    ? Needs assistance Yes ? No ? No. People…….. Needs assistance Yes ? No ? No. People…… Skin

     Pressure ulcers Grade and location: Pressure ulcer risk score Braden/Waterlow (please circle) Yes ? No ?

    Nutrition

    Special diet Yes ? No ? Diabetic Yes ? No ? MUST score ……. Swallowing: normal ? impaired ? Nil by mouth ? Food consistency:

    Normal oral fluids and diet ? Modified oral fluids and diet ? Pureed/soft diet ? Fed via NG/PEG ?

    Feeding: Independent ? Needs assistance ? No. People…….. Non-physical

    Cognition/perception No significant impairment ? Impaired ?

    Behaviour No significant impairment ? Impaired ?

    Mood No significant impairment ? Impaired ?

    Anxiety No significant impairment ? Impaired ?

    Depression No significant impairment ? Impaired ?

    Delirium No significant impairment ? Impaired ?

    Communication Independent ? Impaired ?

    Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

Date Signature Designation

    2. Home Situation

    Accommodation Lives with Facilities Property Owner

    ? Lifeline alarm

    ? Warden

    ? Pull cords

    ? Telephone

    Previous Mobility

    Indoors Outdoors Stairs Access Internal/External

    Previous Transfers Ability

     Type and/or equipment

    Type of Transfer Ability Location in situ ? Chair ? Toilet ? Commode ? Bed ? Bath ? Shower

     Previous level of Previous level of Domestic ADLs independence Personal ADLs independence ? Meal Preparation ? Washing ? Transport ? Dressing ? Shopping ? Feeding ? pension/bills ? Cleaning/laundry ? Medication

    Other Key Information

    Is there a history of falls?

Problems Identified:

Other Services/Support (inc Social Services)

    Hobbies/Interests:

Employment Status: Driving Status:

    Communication

    Sight Hearing Speech Glasses Yes ? No ?

    Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

    Please place patient sticker here

     Merseyside & Cheshire

    Clinical Networks

    Contacts Yes ? No ?

    Review Yes ? No ?

    Rehabilitation Complexity Scale Extended (RCS-E) Trauma version

     0 1 2 3 4 5 6

    Potentially Acute

    Unstable medical/ TU MTC Medical Non-active Basic Specialist surgical

     1:1

     Care Independent 1 carer 2 carers ? 3 carers supervision Risk None Low Medium High Very high

     Specialist High

     Nursing None Qualified Rehab nurse nursing dependency Therapy

     Disciplines None 1 2-3 4-5 ? 6

    Moderate High Therapy Low level (e.g. daily (+ asst) Intensity

    (< daily 15-24 25-30 Very High (total therapist

    time) None <15hrs/wk) hrs/wk) hrs/wk >30 hrs/wk Equipment None Basic Specialist

    RCSE: M…… C…… R….. N….. TD….. TI….. Total…../24

    Recommendations for further rehabilitation & rationale

     Date Date

     Referred Transferred

     Acute

Rehabilitation Network

    Hub Unit

Rehabilitation Network

    Spoke Unit

Specialist Spoke Unit

     Rehabilitation Network

    Extended

    Rehabilitation Unit

    Rehabilitation Prescription and Passport Final Version 1 December 2012. Review Date: July 2013

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