Rehabilitation after Critical Illness
Multi- Professional Pathway & Prescription
Trust Logo
Comprehensive
Clinical Assessment
Affix Patient Label
Or
NHS number: …………………………………………………………….
Hospital Number: ……………………………………………………..
Surname: ………………………………………………………………….
Forename: ……………………………………………………………….
D.O.B.
………………………………………………………………..
Address: ………………………………………………………………..
……………………………………………………………………
Date admitted to Critical Care
Name
Lead Rehabilitation Practitioner
Rehabilitation Prescription Document Commenced
Signature
Date
Comprehensive Clinical Assessment completed:
Critical
First comprehensive clinical assessment
Care
On Step down to Level 2
On discharge From Critical Care to the Ward
Signature
Date
Signature
Date
Signature
Date
Ward
Discharge
Ward
Critical
Care
Discharge
Ward based care
On discharge from hospital to home / community
Follow up clinic / Rehabilitation class (2-3 months
after discharge)
Action
Information booklet given to patient or family
Patient diary commenced
Information booklet given to patient on discharge from
Critical Care
Rehabilitation manual given to patient
Patient given a copy of their Critical Care discharge
summary
GP sent a copy of Critical Care discharge summary
Patient diary returned
Follow up / rehabilitation appointment made
Discharged form clinic / rehabilitation class
Final letter sent to GP
Discharged from rehabilitation pathway
Patient experience feedback requested
Rehabilitation Prescription Document Completed
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
1
COMPREHENSIVE CLINICAL ASSESSMENT – 1st Assessment
Plus Functional Assessment by Physiotherapist
PHYSICAL
NONPHYSICAL
PHYSICAL
Fatigue
Breathlessness
Tracheostomy
Swallowing problems
Poor nutritional status
ACTIVITIES OF DAILY LIVING
Minor assistance required
Major assistance required
Total assistance required
SENSORY
Changes in vision
Changes in hearing
Altered sensation
Pain
COMMUNICATION
Difficulties in speech
Change in quality of voice
Difficulty writing
OTHER
Hair loss
Problems with wound healing
ANXIETY / DEPRESSION
Palpitations, irritability or sweating
Nightmares
Hallucinations
Delusions
Flashbacks
Withdrawal
COGNITIVE PROBLEMS
Delirium
Loss of memory
Attention deficit
Sequencing problems
Lack of organisational skills
Confusion
Disinhibition
OTHER
Low self esteem
Low self-image problems
Relationship difficulties
Difficulty sleeping
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Short & medium term goals should be identified from the factors assessed
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
2
Date
Rehabilitation Goal
Refer/Review:
Rehabilitation Plan
Date
Achieved
Signature
Progress Notes:
Critical Care Rehabilitation Prescription
Functional
Assessment
Nutritional
Assessment
Cognitive
Assessment
Psychological Patient experience/
Assessment
Communication
Completed
(Date/Initials)
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
3
COMPREHENSIVE CLINICAL ASSESSMENT – On discharge from Critical Care
Plus Functional Assessment by Physiotherapist
PHYSICAL
NONPHYSICAL
PHYSICAL Fatigue
Breathlessness
Tracheostomy
Swallowing problems
Poor nutritional status
ACTIVITIES OF DAILY LIVING
Minor assistance required
Major assistance required
Total assistance required
SENSORY
Changes in vision
Changes in hearing
Altered sensation
Pain
COMMUNICATION
Difficulties in speech
Change in quality of voice
Difficulty writing
OTHER
Hair loss
Problems with wound healing
ANXIETY / DEPRESSION
Palpitations, irritability or sweating
Nightmares
Hallucinations
Delusions
Flashbacks
Withdrawal
Traumatic memories of Critical Care
COGNITIVE PROBLEMS
Delirium
Loss of memory
Attention deficit
Sequencing problems
Lack of organisational skills
Confusion
Disinhibition
OTHER
Low self esteem
Low self-image problems
Relationship difficulties
Difficulty sleeping
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Short & medium term goals should be identified from the factors assessed
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
4
Date
Rehabilitation Goal
Refer/Review:
Rehabilitation Plan
Date
Achieved
Signature
Progress Notes:
Critical Care Rehabilitation Prescription
Functional
Assessment
Nutritional
Assessment
Cognitive
Assessment
Psychological Patient experience/
Assessment
Communication
Completed
(Date/Initials)
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
5
COMPREHENSIVE CLINICAL ASSESSMENT – Ward Based Care
Plus Functional Assessment by Physiotherapist
PHYSICAL
NONPHYSICAL
PHYSICAL
Fatigue
Breathlessness
Tracheostomy
Swallowing problems
Poor nutritional status
ACTIVITIES OF DAILY LIVING
Minor assistance required
Major assistance required
Total assistance required
SENSORY
Changes in vision
Changes in hearing
Altered sensation
Pain
COMMUNICATION
Difficulties in speech
Change in quality of voice
Difficulty writing
OTHER
Hair loss
Problems with wound healing
ANXIETY / DEPRESSION
Palpitations, irritability or sweating
Elevated HAD score
Nightmares
Hallucinations
Delusions
Flashbacks
Withdrawal
Traumatic memories of Critical Care
COGNITIVE PROBLEMS
Delirium
Loss of memory
Attention deficit
Sequencing problems
Lack of organisational skills
Confusion
Disinhibition
OTHER
Low self esteem
Low self-image problems
Relationship difficulties
Difficulty sleeping
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Short & medium term goals should be identified from the factors assessed
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
6
Date
Rehabilitation Goal
Refer/Review:
Rehabilitation Plan
Date
Achieved
Signature
Progress Notes:
Critical Care Rehabilitation Prescription
Functional
Assessment
Nutritional
Assessment
Cognitive
Assessment
Psychological Patient experience/
Assessment
Communication
Completed
(Date/Initials)
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
7
PHYSICAL
NONPHYSICAL
COMPREHENSIVE FUNCTIONAL ASSESSMENT – On discharge from Hospital
Plus Functional Assessment by Physiotherapist
PHYSICAL
Y/N Comment
Fatigue
Breathlessness
Tracheostomy
Swallowing problems
Poor nutritional status
ACTIVITIES OF DAILY LIVING
Y/N Comment
Minor assistance required
Major assistance required
Total assistance required
SENSORY
Y/N Comment
Changes in vision
Changes in hearing
Altered sensation
Pain
COMMUNICATION
Y/N Comment
Difficulties in speech
Change in quality of voice
Difficulty writing
OTHER
Hair loss
Problems with wound healing
Social care needs
Equipment needs
ANXIETY / DEPRESSION
Y/N Comment
Palpitations, irritability or sweating
Elevated HAD score
Nightmares
Hallucinations
Delusions
Flashbacks
Withdrawal
Traumatic memories of Critical Care
COGNITIVE PROBLEMS
Y/N Comment
Delirium
Loss of memory
Attention deficit
Sequencing problems
Lack of organisational skills
Confusion
Disinhibition
OTHER
Y/N Comment
Low self esteem
Low self-image problems
Relationship difficulties
Difficulty sleeping
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
8
Date
Rehabilitation Goal
Refer/Review:
Rehabilitation Plan
Date
Achieved
Signature
Progress Notes:
Critical Care Rehabilitation Prescription
Functional
Assessment
Nutritional
Assessment
Cognitive
Assessment
Psychological Patient experience/
Assessment
Communication
Completed
(Date/Initials)
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
9
COMPREHENSIVE ASSESSMENT – Follow-up/2-3 months after discharge
Plus Functional Assessment by Physiotherapist
PHYSICAL
NONPHYSICAL
PHYSICAL
Fatigue
Breathlessness
Tracheostomy
Swallowing problems
Poor nutritional status
ACTIVITIES OF DAILY LIVING
Minor assistance required
Major assistance required
Total assistance required
SENSORY
Changes in vision
Changes in hearing
Altered sensation
Pain
COMMUNICATION
Difficulties in speech
Change in quality of voice
Difficulty writing
OTHER
Hair loss
Problems with wound healing
Social care needs
Equipment needs
ANXIETY / DEPRESSION
Palpitations, irritability or sweating
Elevated HAD score
Nightmares
Hallucinations
Delusions
Flashbacks
Withdrawal
Traumatic memories of Critical Care
COGNITIVE PROBLEMS
Delirium
Loss of memory
Attention deficit
Sequencing problems
Lack of organisational skills
Confusion
Disinhibition
OTHER
Low self esteem
Low self-image problems
Relationship difficulties
Difficulty sleeping
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Y/N
Comment
Critical Care Rehabilitation Prescription
Functional
Assessment
Nutritional
Assessment
Cognitive
Assessment
Psychological Patient experience/
Assessment
Communication
Completed
(Date/Initials)
On going needs:
Further Action:
Refer to:
Date
Action
Final Letter to GP
Discharged from pathway
Rehabilitation after Critical Illness Multi- Professional Pathway
Supported by SEC ODN August 2014
Signature
Sign
Date
11