Key objectives

To provide patients with a digital eRehabilitation Prescriptions following discharge from hospital after a serious injury.

The eRehabilitation Prescription is part of a 3-step discharge process, helping trauma patients leaving hospital to manage their aftercare better.

It includes:

eRehabilitation Prescription – a tailored care plan informing patients about what has happened to them and signposting support services to advise about commonly confronted problems.
Discharge consultation – a detailed consultation conducted in collaboration with patients and their specialist healthcare professional (i.e. trauma practitioner and pharmacist) before leaving hospital.
Two-week follow-up phone call / ongoing access and online consultation via Patients Know Best – to reinforce the contents of the eRehabilitation Prescription and move forward using online consultations and remote monitoring.

Outcome measures

To register a patient on PKB and pre-populate the demographics and appointments in PKB.
To use a standards-based approach to enable the solution to be reused with other PHRs.
Share care plan via third-party systems using PKB's API's.

Current Baselines

Patients left the acute hospital with no care plan, no documentation of their stay or treatments and primary care wasn't alwaysinformation of the acute hospital admission.

“Our feedback told us that patients, and sometimes their families or carers, felt like they’d been ‘forgotten’ once they left the hospital and there really was no sort of care plan in place to help with that.”

Workflow

Patient: Claim their PKB record
Team: Add carer to the record
Carer: Claims PKB record and views patients record
Team: Adds care plan and diary entry to the patients PKB record
Carer: Views patients PKB record
Team: Discharges patient with complete history in their PKB record
Team: Share Rehab prescription care plan with third party system via PKBs APIs
Patient: Views history of stay and rehab care plan
Third party systems: Views patients care plan and data in the PKB record

Rehab Prescription Care Plan Template

“If you have a patient that comes in with a head injury and they have short-term memory loss, they can’t always retain the information they’re being told. By using Patients Know Best, it means that when going home or to a local hospital, the information is there and can be reiterated and utilised when needed.”

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<p><strong style="color: #ffffff;">Outstanding Needs:</strong></p>

</div>

Transfer/Discharge Date

<br />

<textarea class="form-control" rows="10" name="ongoing_procedures" style="width:100%;">Actions for GP:

Actions for next care provider:

Action for patient:

Rehabilitation:</textarea>

</div>

</div>

<label for="Kin_contact">Next of Kin contact number:</label>

</div>

<hr />

</div>

<label for="GP">GP and address:</label>

</div>

<label for="current_loc">Current location:</label>

</div>

</div>

<hr />

</div>

<label for="consultant">Lead Consultant: </label>

</div>

<label for="professional_contacts_invovled">MTC contacts</label>

</div>

<label for="mtcoordinator">Major Trauma Coordinator</label>

</div>

<label for="mtcoordinator">Telephone number:</label>

</div>

<p><strong style="color: #ffffff;">Pre-injury information</strong></p>

</div>

<label for="past_med_history">Significant past medical history</label>

</div>

</div>

<hr />

</div>

<label for="social_support">Social support</label>

</div>

</div>

<hr />

</div>

<label for="environment">Housing/home environment</label>

</div>

</div>

<hr />

</div>

<label for="workOptions">Work/vocation/roles</label>

</div>

<option value="--">Select </option>

<option value="Full/PT Education">Full/PT Education</option>

<option value="Employed">Employed</option>

<option value="Unemployed">Unemployed</option>

<option value="Childcare/Carer">Childcare/Carer</option>

<option value="Retired">Retired</option>

<option value="Other">Other</option>

</select>

</div>

<hr />

</div>

<label for="Leisure">Leisure</label>

</div>

</div>

<hr />

</div>

<label for="func_status">Functional Status <br/> Mobility, transfers, ADLs</label>

</div>

</div>

<p><strong style="color: #ffffff;">Date and Mechanism of injury</strong></p>

</div>

<p><strong style="color: #ffffff;">Date of admission</strong></p>

</div>

<p class="visible-xs visible-sm"><strong>Date and Mechanism of injury</strong></p>

</div>

<p class="visible-xs visible-sm"><strong>Date of admission</strong></p>

</div>

<label for="cp_descriptionInjury"><strong style="color:#ffffff;">Description of Injury</strong></label>

</div>

</div>

<div>

<p><strong style="color: #ffffff;">Ongoing Rehabilitation Needs</strong></p>

</div>

</div>

<p><i>Optional to select category</i></p>

</div>

<input class="form-check-input" type="checkbox" value="Specialist inpatient" name="cp_inpatient" id="cp_inpatient"> Specialist inpatient</input>

</div>

<input class="form-check-input" type="checkbox" value="Category A" name="cp_category_a" id="cp_category_a"> Category A</input>

</div>

<input class="form-check-input" type="checkbox" value="Category B" name="cp_category_b" id="cp_category_b"> Category B</input>

</div>

<input class="form-check-input" type="checkbox" value="Specialist outpatient" name="cp_outpatient" id="cp_outpatient"> Specialist outpatient</input>

</div>

<input class="form-check-input" type="checkbox" value="Multidisciplinary" name="cp_multidisciplinary" id="cp_multidisciplinary"> Multidisciplinary</input>

</div>

<input class="form-check-input" type="checkbox" value="Single Discipline" name="cp_singleDiscipline" id="cp_category_b"> Single Discipline</input>

</div>

<input class="form-check-input" type="checkbox" value="Non-specialist outpatient" name="cp_nonSpecIpatient" id="cp_outpatient"> Non-specialist inpatient</input>

</div>

<input class="form-check-input" type="checkbox" value="Category C" name="cp_category_c" id="cp_category_c"> Category C</input>

</div>

<input class="form-check-input" type="checkbox" value="Community Rehabilitation" name="cp_commRehab" id="cp_commRehab"> Community Rehabilitation</input>

</div>

<input class="form-check-input" type="checkbox" value="Specialist MDT" name="cp_specialistMDT" id="cp_specialistMDT"> Specialist MDT</input>

</div>

<input class="form-check-input" type="checkbox" value="Generic MDT" name="cp_genericMDT" id="cp_genericMDT"> Generic MDT</input>

</div>

<input class="form-check-input" type="checkbox" value="No Ongoing Rehabilitation Needs" name="cp_noRehabNeeds" id="cp_noRehabNeeds"> No Ongoing Rehabilitation Needs</input>

</div>

</div>

<p><strong>Onward Referral for rehabilitation</strong></p>

<br />

</div>

<label for="cp_apptsExpect"><b>What appointments should you expect after discharge:</b></label>

</div>

<label for="cp_lookFor">What you and your carer/family should look out for:</label>

</div>

<p><strong style="color: #ffffff;">Rehabilitation needs checklist</strong></p>

</div>

<p><strong>Physical impairment requiring rehabilitation</strong> </p>

<option value="--">Please select</option>

</select>

</div>

<input class="form-check-input" type="checkbox" value="Brain injury with prolonged disorder of consciousness (PDOC i.e. vegetative or minimally concious state)" name="cp_brainInjury1" id="cp_brainInjury1"> Brain injury with prolonged disorder of consciousness (PDOC i.e. vegetative or minimally concious state)</input>

</div>

<input class="form-check-input" type="checkbox" value="Brain injury without prolonged disorder of consciousness" name="cp_brainInjury2" id="cp_brainInjury2"> Brain injury without prolonged disorder of consciousness</input>

</div>

<input class="form-check-input" type="checkbox" value="Tracheostomy weaning" name="cp_tracheostomyWeaning" id="cp_tracheostomyWeaning"> Tracheostomy weaning</input>

</div>

<input class="form-check-input" type="checkbox" value="Spinal cord injury - ventilated" name="cp_spinal1" id="cp_spinal1"> Spinal cord injury - ventilated</input>

</div>

<input class="form-check-input" type="checkbox" value="Spinal cord injury - Not ventilated" name="cp_spinal2" id="cp_spinal2"> Spinal cord injury - Not ventilated</input>

</div>

<input class="form-check-input" type="checkbox" value="Spinal fractures - no neurology" name="cp_spinal3" id="cp_spinal3"> Spinal fractures - no neurology</input>

</div>

<input class="form-check-input" type="checkbox" value="Single complex fracture or dislocation" name="cp_singleComplex" id="cp_singleComplex"> Single complex fracture or dislocation</input>

</div>

<input class="form-check-input" type="checkbox" value="Multiple fractures" name="cp_multipleFracture" id="cp_multipleFracture"> Multiple fractures</input>

</div>

<input class="form-check-input" type="checkbox" value="Amputee" name="cp_amputee" id="cp_amputee"> Amputee</input>

</div>

<input class="form-check-input" type="checkbox" value="Brachial plexus injury/peripheral nerve injury" name="cp_brachialPlexus" id="cp_brachialPlexus"> Brachial plexus injury/peripheral nerve injury</input>

</div>

<input class="form-check-input" type="checkbox" value="Chest trauma" name="cp_chestTrauma" id="cp_chestTrauma"> Chest trauma</input>

</div>

<input class="form-check-input" type="checkbox" value="Other" name="cp_physImpOther" id="cp_physImpOther"> Other</input>

</div>

<input class="form-check-input" type="checkbox" value="Facial injuries (inc visual loss)" name="cp_facialInjury1" id="cp_facialInjury1"> Facial injuries (inc visual loss)</input>

</div>

<input class="form-check-input" type="checkbox" value="Thorax (inc ribs, lungs, diaphragm, sternum)" name="cp_ThoraxInjury1" id="cp_ThoraxInjury1"> Thorax (inc ribs, lungs, diaphragm, sternum)</input>

</div>

<input class="form-check-input" type="checkbox" value="Abdomen and Pelvis" name="cp_abdomenInjury1" id="cp_abdomenInjury1"> Abdomen and Pelvis</input>

</div>

<input class="form-check-input" type="checkbox" value="Upper limb: single complex fracture or dislocation" name="cp_singleFractureInjury1" id="cp_singleFractureInjury1"> Upper limb: single complex fracture or dislocation</input>

</div>

<input class="form-check-input" type="checkbox" value="Upper limb: multiple fractures" name="cp_multipleFractureInjury1" id="cp_multipleFractureInjury1"> Upper limb: multiple fractures</input>

</div>

<input class="form-check-input" type="checkbox" value="Upper limb: limb reconstruction" name="cp_limbReconstructionInjury1" id="cp_limbReconstructionInjury1"> Upper limb: limb reconstruction</input>

</div>

<input class="form-check-input" type="checkbox" value="Upper limb: amputee" name="cp_amputeeInjury1" id="cp_amputeeInjury1"> Upper limb: amputee</input>

</div>

<input class="form-check-input" type="checkbox" value="Lower limb: single complex fracture or dislocation" name="cp_singleFractureInjury2" id="cp_singleFractureInjury2"> Lower limb: single complex fracture or dislocation</input>

</div>

<input class="form-check-input" type="checkbox" value="Lower limb: Pelvic Fracture" name="cp_pelvicFractureInjury1" id="cp_pelvicFractureInjury1"> Lower limb: Pelvic Fracture</input>

</div>

<input class="form-check-input" type="checkbox" value="Lower limb: Multiple fractures" name="cp_multipleFractureInjury2" id="cp_multipleFractureInjury2"> Lower limb: Multiple fractures</input>

</div>

<input class="form-check-input" type="checkbox" value="Lower limb: Limb reconstruction" name="cp_limbReconstructionInjury2" id="cp_limbReconstructionInjury2"> Lower limb: Limb reconstruction</input>

</div>

<input class="form-check-input" type="checkbox" value="Lower limb: Amputee" name="cp_amputeeInjury2" id="cp_amputeeInjury2"> Lower limb: Amputee</input>

</div>

<input class="form-check-input" type="checkbox" value="Nerve injury (inc brachial/lumbar plexus, peripheral nerve)" name="cp_nerveInjury1" id="cp_nerveInjury1"> Nerve injury (inc brachial/lumbar plexus, peripheral nerve)</input>

</div>

<input class="form-check-input" type="checkbox" value="External (inc burns, lacerations, degloving)" name="cp_externalInjury1" id="cp_externalInjury1"> External (inc burns, lacerations, degloving)</input>

</div>

<p><strong>Cognitive or mood disturbance requiring rehabilitation</strong> </p>

<option value="--">Please select</option>

</select>

</div>

<input class="form-check-input" type="checkbox" value="Communication difficulties" name="cp_commDiff" id="cp_commDiff"> Communication difficulties</input>

</div>

<input class="form-check-input" type="checkbox" value="Cognitive difficulties" name="cp_cogDiff" id="cp_cogDiff"> Cognitive difficulties</input>

</div>

<input class="form-check-input" type="checkbox" value="Challenging behaviour" name="cp_challengingBehaviour" id="cp_challengingBehaviour"> Challenging behaviour</input>

</div>

<input class="form-check-input" type="checkbox" value="Mental Health difficulties pre-injury" name="cp_preinjuryMH" id="cp_preinjuryMH"> Mental Health difficulties pre-injury</input>

</div>

<input class="form-check-input" type="checkbox" value="Mental Health difficulties post injury" name="cp_postinjuryMH" id="cp_postinjuryMH"> Mental Health difficulties post injury</input>

</div>

<input class="form-check-input" type="checkbox" value="Emotional difficulties" name="cp_emoDiff" id="cp_emoDiff"> Emotional difficulties</input>

</div>

<input class="form-check-input" type="checkbox" value="Other" name="cp_cogOther" id="cp_cogOther"> Other</input>

</div>

<p><strong>Psychosocial issues (that may impact rehabilitation)</strong> </p>

<option value="--">Please select</option>

</select>

</div>

<input class="form-check-input" type="checkbox" value="Housing/accomodation" name="cp_houseAcc" id="cp_houseAcc"> Housing/accomodation</input>

</div>

<input class="form-check-input" type="checkbox" value="Drug/alcohol misuse" name="cp_drugAlc" id="cp_drugAlc"> Drug/alcohol misuse</input>

</div>

<input class="form-check-input" type="checkbox" value="Complex medico-legal issues including best interest decisions, safeguarding and DOLS" name="cp_medicoLegal" id="cp_medicoLegal"> Complex medico-legal issues including best interest decisions, safeguarding and DOLS</input>

</div>

<input class="form-check-input" type="checkbox" value="Educational" name="cp_Educational" id="cp_Educational"> Educational</input>

</div>

<input class="form-check-input" type="checkbox" value="Referred to violence reduction team" name="cp_violence" id="cp_violence"> Referred to violence reduction team</input>

</div>

<input class="form-check-input" type="checkbox" value="Vocational/job role requiring specialist vocational rehabilitation" name="cp_vocational" id="cp_vocational"> Vocational/job role requiring specialist vocational rehabilitation</input>

</div>

<input class="form-check-input" type="checkbox" value="Other" name="cp_psychoOther" id="cp_psychoOther"> Other</input>

</div>

<label for="cp_rehabPrescDev">Has the Rehabilitation Prescription been developed with the involvement of the patient and/or their family/carer?</label>

<option value="--">Select</option>

<option value="Not Appropriate">Not Appropriate</option>

</select>

</div>

<label for="cp_rehabPrescDiscuss">Has the Rehabilitation Prescription been discussed with the patient where possible?</label>

<option value="--">Select</option>

<option value="Not Appropriate">Not Appropriate</option>

</select>

</div>

<label for="cp_patientComments">Patient Comments</label>

</div>

<h3>The Rehabilitation Prescription has been distributed to:</h3>

</div>

<input class="form-check-input" type="checkbox" value="Other" name="cp_distributionProvider" id="cp_distributionProvider"> Next care provider</input>

</div>

<input class="form-check-input" type="checkbox" value="Other" name="cp_distributionPatient" id="cp_distributionPatient"> Patient</input>

</div>

<h3>You can use your personal diary to log your questions and thoughts. This will not be read unless you so request.</h3>

<h2>Assessed by:</h2>

<label for="cp_assessedByProfession">Profession:</label>

</div>

<h2>RP Completed by:</h2>

<option value="--">Select</option>

<option value="Consultant in Rehabilitation Medicine">Consultant in Rehabilitation Medicine</option>

<option value="Specialist Trainee in Rehabilitation Medicine">Specialist Trainee in Rehabilitation Medicine</option>

<option value="Band 7 Specialist clinician">Band 7 Specialist clinician</option>

<option value="Major Trauma Coordinator">Major Trauma Coordinator</option>

</select>

</div>