Standard 11: Rehabilitation (Version 11)

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.

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 based on functional assessment (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. Rehabilitation plan record (REH-FRM-001).

Pass when. Every plan links its interventions to the assessed impairment.

Immediate fail (any one means the criterion is not met). A patient given a standard exercise protocol with no functional assessment on file.

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.

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.

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.

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. 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. 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.

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.

Sample. Review the progress records for 15 patients on rehabilitation programmes lasting more than 4 weeks.

Immediate fail (any one means the criterion is not met). Progress recorded only as “improving” over six months with no tool or score.

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.

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. Assistive device fitting and training record (REH-FRM-003).

Pass when. Every device has a fitting record.

Immediate fail (any one means the criterion is not met). A wheelchair issued without fitting, with no caregiver training.

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.

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. 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. 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.

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.

Sample. Review the assessment records for 20 patients at the start of physiotherapy treatment.

Immediate fail (any one means the criterion is not met). A patient with a new neurological deficit treated without urgent medical referral.

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.

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.

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.

Sample. Review the home advice records for 15 patients discharged with a home exercise programme.

1. 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.

Immediate fail (any one means the criterion is not met). A patient sent home with exercises not written down or explained.