TVRN – First Rehabilitation Prescription
Notes on using it
This is a set of guidance notes on completing the form.
General
Please never use abbreviations of any sort. “ Lt. NOF” is not acceptable; it should be “fractured
left neck of femur” (or similar)
Please never use and eponymous name (i.e. name of a person used in place of specific detail).
“Left Bennett’s fracture” is not acceptable; it should be “Fracture of the base of the left first metacarpal
bone extending into carpometacarpal joint”. It is unlikely that the eponym of one speciality will be
know outside that speciality.
Please always use the simplest words possible, avoiding jargon. People have and use their arm,
not their ‘upper limb’. This does not mean that you should avoid longer words or rarer words if
they are appropriate.
Please avoid any judgemental words or phrases. “She shouts obscene words at anyone passing by”
is an acceptable, factual statement. “She is rude to people” is (a) attributing a characterstic to the
patient and (b) is less informative.
Please try to give specific examples as evidence rather than giving general statements. “He is
difficult to transfer” is non-specific; “He needs two people to transfer because he is very unsteady
(ataxic) when standing” is much better.
Do not use euphemisms – they are easily misunderstood. As long as you give specific examples
of behaviour without being judgemental, it is OK.
In the document that follows, comments are in italics.
TVRN – First Rehabilitation Prescription.
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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 A brief description of what happened
Mode of transfer to Centre
Wards and departments
Date
Ward and Hospital
Date (and time)
Method
Place
Comment
Note any major events that occurred there
Transfer to:
This is the destination
This prescription:
Date completed:
Completed by: Give name, profession, grade/speciality
TVRN – First Rehabilitation Prescription.
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Injuries and significant complications (with dates):
This is probably best as a simple list
Add any significant complications such as epilepsy, chest infections, Deep Vein Thrombosis, Skin
Pressure Ulceration etc
Major treatment and interventions (with dates):
This is probably best as a simple list, preferably in time order
Give the date, and a brief but informative description (usually what is written on operation note, if a
surgical intervention).
This will cover matters such as dialysis, ventilatory support, circulatory support, transfusions and
unusual anti-biotics for unusual infections
TVRN – First Rehabilitation Prescription.
Item
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Functional Performance - 1
Barthel ADL Index
Score
Comment
Try always to add a comment here
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
Please also use the scores and enter the total
TVRN – First Rehabilitation Prescription.
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Functional Performance – 2
Please answer each question yes or no giving evidence or examples in the comment column.
These all depend purely on observing behaviour, and do not require specific expertise
Question
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)
Answer
(yes/no)
Comment
State what you observe
State what you observe
Give some behavioural evidence
Give some behavioural evidence
Describe some examples
Give some examples
Give an example
Give an example
If low awareness, give Glasgow Coma Scale items
Current Care Plan
You may attach any printed care plan provided the domains are covered.
This needs review by a nurse!
Domain
Respiration
Circulation
Nutrition, swallow
Diet
Skin care
Urinary excretion
Bowel excretion
Use/provision of any
specialist equipment.
Care plan
TVRN – First Rehabilitation Prescription.
Family support
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TVRN – First Rehabilitation Prescription.
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Current areas of concern or ongoing activity.
Free text description of any major issues; especially risks and Mental Capacity
Specifically mention Mental Capacity and any discussions on resuscitation and treatment of lifethreatening illness. What is the current policy (and on what basis)?
Rehabilitation – prognosis
Outline any prognostic information both specific and general, indicating levels of uncertainty
Try to give some broad expectations, in relations to the patient’s losses. Indicate if these have not yet been
discussed with patient (e.g. if comatose)
Rehabilitation – prescription
Outline as appropriate (a) specific actions/activities needed and (b) general thrust of
rehabilitation programme needed.
Give two types.
Specific advice/actions relevant to next two weeks
General recommendation about needs both now, and in medium term (2 week and later).
TVRN – First Rehabilitation Prescription.
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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?