rehabilitation prescription additional information

TVRN – rehabilitation prescription additional information
This is a document that usually will be completed either by the patient with help from staff,
relatives or friends if needed or by close relatives and/or friends if the patient is unable to
complete it.
It covers areas that are vital to successful rehabilitation. Some of it is in the form of direct
questions, but most is simply for the person to fill in with their own words.
The questions are all directed at the patient. If you are filling in on the patient’s behalf, we
apologise but please complete them appropriately
Background information
This is important. The patient information we have may be incorrect, and this is a double
check. The main contact will be the person filling in the form if the patient cannot do it.
Otherwise the main contact should be someone that the patient and contact agree is the best
person to contact if more information is needed. We will be contacting everyone at 6 and 12
months, and it is helpful to have a second contact incase we cannot get in touch with the
Home address:
(mobile & other)
Contact person
NHS no:
Name or names of people completing the form:
Date completed:
Main contact
(mobile & other)
This is obviously of great importance. The questions cannot cover everyone’s situation and you
should fill this is as you think best. Do add explanatory notes if you want, or explain to a
member of the healthcare team.
At the time of the accident were you homeless or
living in short-term rented accommodation that will
not be available when you leave hospital?
If ‘yes’, then is there any accommodation you are
likely to be able to go to?
Considering the accommodation you are able or most likely to return to:
What is its address (if not the ‘home address’
Who else is living there?
Family, friends etc.
Is it rented, and if so who from?
What is the access from the road/street like?
Is it level? Are there steps? Could a person in a
wheelchair get in?
Is the accommodation all on one level?
Are there two or more floors? Are their small steps
within a floor level, for example down into a
Where is the toilet/are the toilets?
Would there be problems in getting to a toilet
Could someone live downstairs if needed?
If the accommodation is more than one floor, is
there space for someone to live downstairs?
How close is your nearest neighbour?
Adjacent house? Only two minutes walk or 50
yards away? Further?
Are there any other possible difficulties that
are relevant?
Personal values, beliefs etc.
This part concerns the sort of person the patient is. Information that could be included
concerns: religious beliefs, attitudes towards health and sickness, what things spark a particular
interest, what the patient’s strengths are, what the patient thinks is important in life etc.
Social networks
This part concerns who the patient knows and has a social relationship with. This could cover:
family members, both close and distant; work colleagues; friends; partner; children; members of
clubs or sports groups etc. Generally it is not necessary to give names. The important point is
that the patient would feel some form of friendship or other positive social relationship towards
the person. Brief descriptions of the groups are helpful.
Work, Social & Leisure Activities
This part concerns the types of activities that the patient undertook including at work and
outside work – what did she or he enjoy doing? These can include both group and solitary
activities. It is helpful, if the person worked, to give a brief description of what the job
Expectations and wishes
This part covers the hopes, expectations and other wishes of the patient.