I. Rehabilitation Medicine (MED)
1. Motor loss (including muscle weakness and limb deficiency)
2. Spasticity/ involuntary movement (including dystonia and ataxia)
3. Joint limitations
4. Autonomic disturbance
5. Sensory deficiency
6. Perceptual and cognitive deficit
7. Associated medical problems
II. Rehabilitation Nursing (NSG)
1. Performance of bowel program
2. Performance of urinary program
3. Performance of skin program
4. Assumes responsibility for self-care
5. Performs assigned interdisciplinary activities
III. Physical Mobility (PHY)
1. Performance of transfers
2. Performance of ambulation
3. Performance of wheelchair mobility (primary mode)
4. Ability to handle environmental barriers (e.g.‚ stairs‚ rugs‚ elevators)
5. Performance of car transfer
6. Driving mobility
7. Assumes responsibility for mobility
IV. Activities of Daily Living (ADL)
1. Performance in fee ding
2. Performance in hygiene/grooming
3. Performance in dressing
4. Performance in home management
5. Performance of mobility in home environment (including utilization of environmental adaptations for communication)
V. Communication (COM)
1. Ability to comprehend spoken language
2. Ability to produce language
3. Ability to read
4. Ability to produce written language
5. Ability to hear
6. Ability to comprehend and use gestures
7. Ability to produce speech
VI. Medications (DRG)
1. Knowledge of medications
2. Skill with medications
3. Utilization of medications
VII. Nutrition (NUT)
1. Nutritional status—body weight
2. Nutritional status—lab values
3. Knowledge of nutrition and/or modified diet
4. Skill with nutrition and diet (adherence to nutritional plan)
5. Utilization of nutrition and diet (nutritional health)
VIII. Assistive Devices (DEV)
1. Knowledge of assistive devices(s)
2. Skill with assuming operating position of assistive device(s)
3. Utilization of assistive device(s)
IX. Psychology (PSY)
1. Distress/comfort
2. Helplessness/self- efficacy
3. Self-directed learning skills
4. Skill in self-management of behavior and emotions
5. Skill in interpersonal relations
X. Neuropsychology (NP)
1. Impairment of short-term memory
2. Impairment of long-term memory
3. Impairment in attention-concentration skills
4. Impairment in verbal linguistic processing
5. Impairment in visual spatial processing
6. Impairment in basic intellectual skills
XI. Social Issues (SOC)
1. Ability to problem solve and utilize resources
2. Family: communication/resource
3. Family understanding of disability
4. Economic resources
5. Ability to live independently
6. Living arrangements
XII. Vocational- Educational Activity (V/E)
1. Active participation in realistic voc/ed planning
2. Realistic perception of work-related activity
3. Ability to tolerate planned number of hours of voc/ed activity/ day
4. Vocational/ educational placement
5. Physical capacity for work
XIII. Recreation (REC)
1. Participation in group activities
2. Participation in community activities
3. Interaction with others
4. Participation and satisfaction with individual leisure activities
5. Active participation in sports
XIV. Pain (consensus) (PAI)
1. Pain behavior
2. Physical inactivity
3. Social withdrawal
4. Pacing
5. Sitting
6. Standing tolerance
7. Walking endurance
XV. Pulmonary Rehabilitation (PUL)
1. Knowledge of pulmonary rehabilitation program
2. Skill with pulmonary rehabilitation program
3. Utilization of pulmonary rehabilitation program
XVI. Patient Participation at Conference
1. Attended N Y
2. Participated in goal setting N Y
3. Family (significant other) attended N Y
XVII. Preparation Completed for Pass and/or Discharge
1. Recreational Therapy pass N Y
2. P.R.N. pass N Y
3. T.L.O.A pass N Y
4. Is this the dis charge conference? N Y
5. Equipment ordered N Y
6. Type of assistive device
7. Phase of device development
8. Therapy schedule set according to priority N Y
9. Rehab. Med. Clinic standard follow-up (1‚ 3‚ 6‚ 12 mo.) N Y
XVIII. Specialty Program
(Specify):
1. __________________
2. __________________
3. __________________
4. __________________
5. __________________
6. __________________
7. __________________
