Appendix 3: Specialist Rehabilitation Prescription Proforma (example).
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1 Appendix 3: Specialist Rehabilitation Prescription Proforma (example). For patients with complex rehabilitation needs requiring Specialist (Level 1 or 2) Rehab services. The specialist rehabilitation Prescription should be complete/ signed off by a Consultant in Rehabilitation Medicine or their deputy at discharge from the Major Trauma Centre / Trauma Unit. This proforma is provided as an exemplar for local adaptation. (Required elements are in red) NHS no: Insert label or: Surname: First name Date of birth: Address: GP: Family contact/ Next of kin Date of Injury: Type(s) of injury: Neurological: Brain injury SCI Peripheral nerve Musculoskeletal Vascular Burns Thoracic Abdominal Amputation Contact phone number for family member Current location: MTC: Consultant: Keyworker: Pre-injury / illness information Significant Past History Family support Housing Work Leisure Description of injuries: (and other details such as initial GCS, PTA etc) Progress/ complications
2 Current functional status: Injuries still requiring active management GCS: E../V../M. Total.. /15 Motor loss: Yes / No Sensory loss: Yes / No Summary of Impairments / function at a glance (This section is optional as the information is included NPDS and Impairment set) Sensory and upper limb Posture and pressure management Mobility Sphincters and Continence Nutrition Ventilatory Cognitive / communication Vision Intact Impaired Unassessable Sitting out Standard chair Special seating Unable Transfers Independent Assisted + 1 Assisted + 2 Hoisted Bladder control Toilet Commode/urinal Catheter/convene Pads Consistency of diet Normal diet/fluids Soft/pureed NG/PEG feed Oxygen support Yes % No Communication Normal Impaired Unable Hearing Intact Impaired Unassessable Pressure relief Independent Assisted + 1 Assisted + 2 Walking Independent Assisted + 1 Assisted + 2 Unable Bladder Assistance Independent Assisted + 1 Assisted + 2 Swallowing Normal Impaired Tracheostomy Yes No Cognitive Normal Impaired Unconscious Perception Intact Impaired Unassessable Pressure sores Yes No Location and grade: Wheelchair None required Independent Assisted No chair Bowel control Toilet Commode Pads Feeding Independent Assisted + 1 Ventilatory support Full support Assisted (CPAP) etc None Behaviour Normal Impaired Upper limb function Intact Impaired Non functional Risk Waterlow Braden Score.. Wandering No Low risk High risk Bowel Assistance Independent Assisted + 1 Assisted + 2 Nutrition MUST score: Details: Mood Normal Impaired Rehabilitation Complexity Scale Extended (RCS-E) Trauma version ( as confirmed by Rehab Physician) Medical None active Basic Specialist Potentially unstable Acute medical / surgical Care Independent 1 carer 2 carers 3 carers 1:1 supervision Risk None Low Medium High Very high Nursing None Qualified Rehab nurse Specialist nursing High dependency Therapy disciplines Therapy None low level Moderate High Intensity (< daily) (eg daily) (+ assistant) <15 hrs/wek hrs/wk hrs/week (Total therapist time) Equipment None Basic Specialist - - None RCSE: M.. C. N. Td.. Ti E.. Total../24 Very high >30 hours/week TU MTC
3 Detail of Rehabilitation needs Optional checklist Medical Medical management Orthopaedic Neurosurgical Amputee Details Physical Mobility Upper limb function Postural support (seating/w/c) Splinting / orthotics Spasticity Pain Basic functions Tracheostomy / ventilator Respiratory / pulmonary rehab Continence urinary / faecal Wound management Swallowing /nutrition Communication ADL Personal care / ADL Continence Extended ADL Vocational Educational Cognitive / psychosocial Sensory (Vision / hearing) Cognitive / perceptual Behavioural management Mood / emotion Formal family support Discharge planning Housing / placement Benefits/finances Equipment / home adaptations Community visits Emotional load on staff Equipment Orthotics/Prosthetics: Mobility aids/transfer equipment Specialist seating Bed/posture Management ADL equipment Other (eg Environmental controls) Any ongoing risks
4 Summary Expected duration of admission Patient category confirmed Service Level required Please ensure the following are completed and entered in the UKROC dataset: Assessment /rapid intervention (2-4 wks) Short stay (eg 6-8 wks) Medium stay (eg 3-4 mths) Long stay (eg 5-6 mths) A B C D Level 1 Level 2a Level 2b Level 3 Other RCS-ET (as above) Full Patient Categorisation Tool Itemised NPDS (for NPCNA) Impairment set If not for rehabilitation: Reason and alternative recommendations: Name and contact details of your key worker: YOUR REHABILITATION PRESCRIPTION: Services referred to: (including contact details and anticipated waiting time) Other key information (eg patient/family wishes. potential barriers to discharge)
5 INFORMATION GIVEN TO PATIENT / FAMILY About their condition and treatment on the MTC About their further treatment / follow-up Other forms of support (eg Headway) Anything else
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