Standards › ASF Health Standards v10 › Standard 34
Standard 34
Rehabilitation
Rehabilitation: individualised plans from functional assessment, team coordination, goals, outcome measurement, assistive devices, discharge planning and aftercare.
Every patient receiving rehabilitation services has an individualised plan built from a documented functional assessment, not a generic protocol applied regardless of the patient’s specific impairment and baseline function.
Why it matters. A rehabilitation plan copied from another patient does not fit the person in front of you. A plan built from a functional assessment, specific to this patient’s goals and abilities, is what makes rehabilitation work.
How the surveyor verifies this criterion
Sample. Review the rehabilitation plans for 20 patients, with the functional assessment each plan is built on.
1. Each patient has a functional assessment recorded before the plan is written.
Method. Check each plan for a functional assessment dated before the plan.
Evidence to show. Individualised rehabilitation plan (REH-POL-001).
Pass when. Every sampled plan is preceded by a functional assessment.
2. The plan is specific to the impairment found in the assessment.
Method. Check each plan for goals and interventions that link to the assessed impairment.
Evidence to show. The rehabilitation plan record (REH-FRM-001).
Pass when. Every plan links its interventions to the assessed impairment.
3. Physiotherapy assessment is on file where the plan includes physiotherapy.
Method. Check each physiotherapy patient for the assessment record.
Evidence to show. Physiotherapy assessment record (PHY-FRM-001, existing, reused).
Pass when. Every physiotherapy patient has an assessment on file.
Immediate fail (any one means the criterion is not met)
- A patient given a standard exercise protocol with no functional assessment on file.
Documents
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Rehabilitation care is coordinated across the relevant disciplines — physical therapy, occupational therapy, speech-language therapy, rehabilitation medicine, nursing, as applicable to the patient — through a shared process, not separate disciplines working in isolation from each other.
Why it matters. A rehabilitation patient often sees a physiotherapist, an occupational therapist, a doctor and a nurse. If they give conflicting advice, the patient is confused and recovery slows.
How the surveyor verifies this criterion
Sample. Review the team coordination records for 15 patients who received care from two or more rehabilitation disciplines.
1. The disciplines involved in each patient’s care are recorded in the plan.
Method. Check each multidisciplinary plan for the disciplines named.
Evidence to show. Multidisciplinary rehabilitation team coordination (REH-SOP-001).
Pass when. Every plan names the disciplines involved.
2. The team reviews each patient at the set interval and records the review.
Method. Check the team review register for each sampled patient against the interval.
Evidence to show. Team review register (REH-REG-001).
Pass when. Every sampled patient has team reviews at the set interval.
3. Conflicting instructions are resolved and the lead clinician is named.
Method. Check each review for any conflict noted and the resolution and lead named.
Evidence to show. Team review register (REH-REG-001).
Pass when. Every recorded conflict has a resolution and a named lead.
Immediate fail (any one means the criterion is not met)
- Two disciplines giving opposite exercise instructions with no lead clinician and no review.
Documents
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Rehabilitation goals are set collaboratively with the patient and, where appropriate, family, in understandable terms, with the patient and family informed of realistic expectations — not goals set unilaterally by the clinical team.
Why it matters. A patient who helps set their own rehabilitation goals is more likely to work towards them. Their family, where appropriate, can help them reach those goals at home.
How the surveyor verifies this criterion
Sample. Review the goal and expectation records for 15 patients, including whether family were involved where appropriate.
1. Goals are recorded with the patient, and with family where the patient agrees.
Method. Check each goal record for the patient’s signature or recorded agreement.
Evidence to show. Patient and family goal-setting and expectations (REH-SOP-002).
Pass when. Every goal record shows the patient’s agreement.
2. Realistic expectations are explained and recorded.
Method. Check each record for the expectation statement and the understanding check.
Evidence to show. The rehabilitation goals and expectations record (REH-FRM-002).
Pass when. Every record states realistic expectations and the check made.
3. Goals are written in understandable terms.
Method. Read a sample of goals for plain-language wording.
Evidence to show. The rehabilitation goals and expectations record (REH-FRM-002).
Pass when. Every sampled goal can be understood by the patient.
Immediate fail (any one means the criterion is not met)
- Goals set by staff with no patient involvement and no explanation of expected recovery.
Documents
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Rehabilitation progress is tracked using a validated functional outcome measurement tool appropriate to the patient’s condition, applied consistently at defined intervals, not relying on informal clinical impression alone.
Why it matters. Saying a patient is improving is not the same as measuring it. A validated functional tool gives a number that can be compared over time and shows whether the treatment is working.
How the surveyor verifies this criterion
Sample. Review the progress records for 15 patients on rehabilitation programmes lasting more than 4 weeks.
1. A validated functional outcome tool is named for each patient.
Method. Check each patient record for the tool name and the condition it suits.
Evidence to show. Measuring progress against goals (PHY-SOP-001, existing, reused).
Pass when. Every sampled patient has a validated tool named.
2. The tool is applied at the defined intervals.
Method. Check the outcome register for each measurement against the interval.
Evidence to show. Outcome review register (PHY-REG-004, existing, reused).
Pass when. Every measurement falls within the defined interval.
3. Progress is recorded as a score, not only as an informal note.
Method. Check each progress entry for a recorded score.
Evidence to show. Outcome review register (PHY-REG-004, existing, reused).
Pass when. Every progress entry includes a recorded score.
Immediate fail (any one means the criterion is not met)
- Progress recorded only as “improving” over six months with no tool or score.
Documents
No documents yet.
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Assistive devices and equipment — mobility aids, orthotics, adaptive equipment — are assessed, fitted, and provided to match the patient’s actual functional need, with patient and caregiver trained in correct use before discharge.
Why it matters. A patient given a wheelchair that is too big, or a brace that does not fit, can fall or develop sores. Devices should match the need and be checked for fit and condition.
How the surveyor verifies this criterion
Sample. Review the equipment and assistive device records for 15 patients issued a device.
1. Each device is assessed for the patient’s functional need before it is issued.
Method. Check each record for the assessment dated before issue.
Evidence to show. Assistive device assessment, provision and training (REH-SOP-003).
Pass when. Every issued device has a need assessment before issue.
2. The device is fitted and the fit is recorded.
Method. Check each record for the fitting entry and the fit result.
Evidence to show. The assistive device fitting and training record (REH-FRM-003).
Pass when. Every device has a fitting record.
3. The patient and caregiver are trained in use and the training is recorded.
Method. Check each record for the training entry for patient and caregiver.
Evidence to show. Mobility equipment register (ACS-REG-001, existing, reused).
Pass when. Every record shows training for the patient and caregiver.
Immediate fail (any one means the criterion is not met)
- A wheelchair issued without fitting, with no caregiver training.
Documents
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Discharge planning for rehabilitation patients begins early in the course of treatment and addresses home environment, caregiver support, community resources, and follow-up therapy — not a last-minute checklist completed at the point of discharge.
Why it matters. Patients who leave rehabilitation without a plan for home and community often fall back. Planning the discharge from the start, with the community and the family, makes the gains last.
How the surveyor verifies this criterion
Sample. Review the discharge and reintegration plans for 15 rehabilitation patients discharged in the last 6 months.
1. Discharge planning starts early and is dated from admission.
Method. Check each plan for the start date against the admission date.
Evidence to show. Discharge and community reintegration planning (REH-SOP-004).
Pass when. Every plan starts within the defined period from admission.
2. The plan addresses home environment, caregiver support, community resources and follow-up therapy.
Method. Check each plan for the four elements.
Evidence to show. The discharge and reintegration plan record (REH-FRM-004).
Pass when. Every plan addresses all four elements.
3. The plan is agreed with the patient and caregiver before discharge.
Method. Check each plan for the patient and caregiver agreement.
Evidence to show. The discharge and reintegration plan record (REH-FRM-004).
Pass when. Every plan is agreed before discharge.
Immediate fail (any one means the criterion is not met)
- A patient with no home access arrangements discharged on the day of referral.
Documents
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
A physiotherapist assesses each patient before treatment begins. The assessment records the problem, the goals, any contraindications, and any red flags that need urgent medical review. Red flags are referred to a doctor, and the treatment goals are agreed with the patient and recorded.
Why it matters. Physiotherapy starts with a clear picture of the patient’s problem, function and goals. Without an assessment before treatment, the treatment is guesswork and cannot be measured later.
How the surveyor verifies this criterion
Sample. Review the assessment records for 20 patients at the start of physiotherapy treatment.
1. An assessment is recorded before treatment begins.
Method. Check each record for an assessment dated before the first treatment.
Evidence to show. Physiotherapy assessment before treatment (PHY-POL-001, existing, reused).
Pass when. Every sampled patient has an assessment before treatment.
2. The assessment records the problem, goals, contraindications and red flags.
Method. Check each assessment for the four elements.
Evidence to show. Physiotherapy assessment record (PHY-FRM-001, existing, reused).
Pass when. Every assessment records all four elements.
3. Red flags are referred for urgent medical review and the referral is recorded.
Method. Check each red flag for the referral and the review outcome.
Evidence to show. Physiotherapy assessment record (PHY-FRM-001, existing, reused).
Pass when. Every red flag has a recorded referral.
Immediate fail (any one means the criterion is not met)
- A patient with a new neurological deficit treated without urgent medical referral.
Documents
No documents yet.
E-learning
No course linked yet.
Planned course: No e-learning course is linked to this criterion yet. A course is planned to cover it.
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Each discharged patient receives a written aftercare plan, explained and checked for understanding, and sent to the next provider.
Why it matters. Patients who leave without a written plan often return or harm themselves. A written, explained plan sent to the next provider keeps the care going.
How the surveyor verifies this criterion
Sample. Review the discharge records for 20 patients discharged from rehabilitation in the last 3 months.
1. A written aftercare plan is given to every discharged patient.
Method. Check each discharge record for the aftercare plan issued.
Evidence to show. Written aftercare plan at discharge (REH-SOP-005).
Pass when. Every discharged patient has a written plan.
2. The plan is explained and understanding is checked.
Method. Check each plan for the explanation and the understanding check recorded.
Evidence to show. The aftercare plan form (REH-FRM-005).
Pass when. Every plan records the explanation and the check.
3. The plan is sent to the next provider.
Method. Check each plan for the transfer to the next provider and the date sent.
Evidence to show. The aftercare plan form (REH-FRM-005).
Pass when. Every plan is sent to the next provider.
Immediate fail (any one means the criterion is not met)
- A patient discharged with no written aftercare plan.
Documents
E-learning
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705
Patients receive written advice and exercises to continue at home, explained to them. Understanding is checked by teach-back as set out in the patient understanding rule.
Why it matters. Most of a patient’s progress happens between visits. Written advice and exercises that the patient understands and can follow at home make the treatment last beyond the clinic.
How the surveyor verifies this criterion
Sample. Review the home advice records for 15 patients discharged with a home exercise programme.
1. Written advice and exercises are given to each patient who continues at home.
Method. Check each record for the written advice given.
Evidence to show. Home advice record (PHY-FRM-004, existing, reused).
Pass when. Every sampled patient has written advice on file.
2. The advice is explained to the patient.
Method. Check each record for the explanation entry.
Evidence to show. Written aftercare plan at discharge (REH-SOP-005).
Pass when. Every sampled record shows the explanation.
3. Understanding is checked by teach-back.
Method. Check each record for the teach-back entry.
Evidence to show. Home advice record (PHY-FRM-004, existing, reused).
Pass when. Every sampled record shows a teach-back check.
Immediate fail (any one means the criterion is not met)
- A patient sent home with exercises not written down or explained.
Documents
No documents yet.
E-learning
References
- World Health Organization. Rehabilitation in health systems. Geneva: WHO; 2019.
Additional resources: guidelines in the GMJ library
These guidelines are held in the GMJ guideline library (news.gmj.ge). WHO and PAHO are the issuing bodies; MSF guidelines are marked MSF.
- Rehabilitation considerations during the COVID-19 outbreak · PAHO · criteria: Whole standard
Integrating rehabilitation into care pathways and maintaining essential rehabilitation during an outbreak (COVID-19).
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