Policies and procedures

There is documentation of policies and procedures to ensure safe, appropriate, accountable, effective and measurable improvement in the patients involved in rehabilitation programs following illness or injury.

Demonstrating the standard

4.1 Patient related care

4.1.1 There are clear written criteria for admission to the Rehabilitation Medicine service. These criteria are made available to referrers.

4.1.2 The rehabilitation medicine service provides consultation and triage to determine appropriateness for admission into the inpatient rehabilitation program and/or advice on alternative care.

4.1.3 There is a clearly defined assessment procedure for each patient admitted to the hospital for rehabilitation.

4.1.4 There is a written rehabilitation plan for each patient based on the assessment. The plan is to be patient centred and states the person’s needs and limitations as well as the goals. The plan is prepared by a multidisciplinary team with the active participation of the patient and family and includes provision for continuing care, review and discharge.

4.1.5 The progress of the patient is evaluated regularly against the established plan with standard measures of function. Documentation of progress forms part of the medical records.

4.1.6 There is a formal planned discharge procedure including provision of a written medical and/or multi-disciplinary discharge summary which should be provided to the patient, the general practitioner and other relevant services. Other direct communication and collaboration with the general practitioner should be undertaken as necessary.

4.1.7 There is documented evidence of weekly case management meetings at which individual program plans are reviewed. These meetings involve the rehabilitation medicine physician and appropriate nursing and allied health professionals.

4.1.8 All patients are offered follow-up care and review as often as it is considered necessary and practical.

4.1.9 Where relevant, there are established links to in-reach, outpatient, day rehabilitation and community rehabilitation services.

4.1.10 Ideally, inpatient services will offer multidisciplinary ambulatory rehabilitation programs post discharge (e.g. early supported discharge, transitional rehabilitation, telehealth, and outreach) to provide continuity of care and community reintegration15.

4.1.11 There are documented policies for liaison and collaboration with general practitioners, primary care and other healthcare providers to ensure continuity and integration of care15.

4.1.12 There are processes to ensure that patients who are capable of returning to work are provided with the best opportunity to do so with direction to appropriate vocational rehabilitation services.

4.1.13 There is a documented policy and evidence of ongoing consultation and communication with referring and treating healthcare practitioners.

4.1.14 There are documented policies for all procedures within the facility with evidence that these are updated regularly.

4.1.15 There are documented policies and effective procedures for the management of patients who might become unwell during the rehabilitation episode and who require acute care assessment, management and/or transfer.

4.2 Management of patient records

4.2.1 There are secure storage and retrieval systems for patient records.

4.2.2 Confidentiality of records is maintained.

4.2.3 Records are retained and accessible for the statutory required periods.

Close overlay