TVRN – First Rehabilitation Prescription
Demographics
Patient
General Practitioner
Name
Name
Home address:
Address:
Telephone
Telephone
(mobile & other)
Email
Contact person
NHS no:
Trauma Centre or Unit
Trauma Centre or Unit
Address
Web-page
Rehabilitation coordinator
Coordinator’s telephone
Coordinator’s email:
Accident
Date and time
Place
Circumstances
Mode of transfer to Centre
Wards and departments
Date
Place
Comment
Transfer to:
Ward and Hospital
Date (and time)
Method
This prescription:
Date completed:
Completed by:
TVRN – First Rehabilitation Prescription.
Injuries and significant complications (with dates):
Major treatment and interventions (with dates):
Page 2
TVRN – First Rehabilitation Prescription.
Item
Functional Performance - 1
Barthel ADL Index
Score
Bowels
0 Incontinent of faeces (or is given enemas)
1 Occasional accident (less than 1x/24 hours)
2 Continent
Bladder
0 Incontinent, or catheterised/convene drain and unable to
manage it him/herself
1 Occasional accident (maximum 1x/24 hours)
2 Continent (for last seven days)
Grooming
0 Needs help (supervision, prompts, or practical help)
1 Independent in washing face, doing teeth, shaving or putting
on make-up, brushing hair
Toilet use
0 Dependent, unable to wipe self
1 Needs help, but can wipe self
2 Independent in transfers and managing clothes off/on
Feeding
0 Unable; is fed, has gastrostomy, or feeds self minimally
1 Needs help cutting food, spreading butter, prompts/supervision
etc
2 Independent with food provided/selected
Transfers
0 Unable; hoisted and/or unable to sit in wheelchair
1 Major help; one or two people, much physical effort
2 Minor help; one person, prompts/supervision or minor physical
effort
3 Independent bed-chair
Mobility
0 Immobile; unable to get from bedroom to dining area
1 Wheelchair independent (electric or self-propelled) at least
bedroom to dining area
2 Walks with help of one person (physical, or
prompts/supervision) from bedroom to dining area
3 Independent. May use stick, rollator etc if necessary
Dressing
0 Dependent
1 Needs help, but does about half (e.g. top or bottom
independently, or minor prompts and/or physical help)
2 Independent, including shoes, laces, buttons etc
Stairs
0 Unable
1 Needs help, physical or supervision/prompts or carrying
equipment
2 Independent up and down stairs (any means, including stair
lift)
Bathing
0 Dependent
1 Independent (bath or shower) including getting in and out,
washing, and drying and hair
Total
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Comment
TVRN – First Rehabilitation Prescription.
Page 4
Functional Performance – 2
Please answer each question yes or no giving evidence or examples in the comment column.
Question
Answer
(yes/no)
Comment
Is the patient able to follow a
three stage command?
E.g. Pick up the cup, drink from
it, and then give it to me.
Is the patient able to describe
an object such that you
understand it?
E.g. Describe this to me?
[holding up a coloured mug with
fluid in it]
Does the patient know where
he/she is, and the month and
year?
Is the patient experiencing
significant emotional distress?
Does the patient’s behaviour
pose a risk to him/herself or
to others?
Does the patient’s behaviour
cause others embarrassment,
or fear, or harm?
Can the patient see to read?
Can the patient hear?
Is the patient in a state of low
awareness, including coma?
Give Glasgow Coma Scale
score (Eyes, Motor, Verbal)
Current Care Plan
You may attach any printed care plan provided the domains are covered.
Domain
Respiration
Circulation
Nutrition, swallow
Diet
Skin care
Urinary excretion
Bowel excretion
Use/provision of any
specialist equipment.
Family support
Care plan
TVRN – First Rehabilitation Prescription.
Page 5
TVRN – First Rehabilitation Prescription.
Page 6
Current areas of concern or ongoing activity.
Free text description of any major issues; especially risks and Mental Capacity
Rehabilitation – prognosis
Outline any prognostic information both specific and general, indicating levels of uncertainty
Rehabilitation – prescription
Outline as appropriate (a) specific actions/activities needed and (b) general thrust of
rehabilitation programme needed.
TVRN – First Rehabilitation Prescription.
Page 7
Drugs and other accompanying material
List all equipment supplied/transferred
Equipment
Reason and how to use
Comment
List all drugs supplied (or attach discharge list)
Drug
Dose, frequency
End date
Comment
Follow up, and future actions
You should have a full, formal review of this prescription by (date), or at the time of discharge
if that is sooner.
The following planned follow up appointments have been made:
Date/time, and place
Who with
Distribution
Copies have been distributed to:
 General Practitioner
 With you to next service (and by fax in advance)
 Your Rehabilitation Prescription Folder
 Thames Valley Rehabilitation Network
 Rehabilitation Coordinator
 Trauma team
Why?