how do you write a rehab consult?

[oreosandsake]

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this is a "homework exercise" that I was given.

I don't have a template to work off of and am looking for advice on how to do this. can anyone please post an example for me to see?

I was given some basic advice to address: premorbid functioning, current levels, and goals. what else goes into this?


thank you

 

[axm397]

this is a "homework exercise" that I was given.

I don't have a template to work off of and am looking for advice on how to do this. can anyone please post an example for me to see?

I was given some basic advice to address: premorbid functioning, current levels, and goals. what else goes into this?


thank you

start with regular H&P - what kind of condition/injury, past medical surgical, meds, allergies, review of system, more extensive social history - who lives with patient, how many steps to enter, how many steps inside, what does the patient do for a living?

physical exam with thorough musculoskeletal and neuro exam, include functional status - premorbid, current, and goal

and then for recommendations do it by system:
such as cardiovascular, pain, neuro including pertinent stuff like spasticity, types of therapy needed, etc.

dont forget discharge planning and social work involvement

 

[lobelsteve]

Just write Dx and ok for transfer to rehab. No one else except your inpt resident reads anything else.

 

[oreosandsake]

thank you for the quick reply.

I wish i could write the second one, but I don't think my attending will accept that from me at this point in my training. 😉

 

[Taus]

I reluctantly have to agree w/ Dr. Lobel....

I'm on a trauma surgery rotation right now and ALL my attendings want to hear from PM&R is if/when they will be transferred to rehab. Then again...I can't remember it being any different on any other rotations over the last 3 years....

Anyway, use your consult time to hone your physical exam skills and learn about the patients pathology. Also, think about how their functional status compares to their pre-morbid levels and demands and familiarize yourself w/ the patient before you get to work w/ them on the inpatient unit. I know there is more to it then that...but as a student that's how I looked at consults and I enjoyed my time doing them.

Attached is a template that I made when I was an MS4 on my elective rotations. It's a little rough around the edges, but hopefully it will be helpfulView attachment PM&R Consult Template.doc I'll edit it when I have time...I'm q3 80-100hrs/week right now...

 

[oreosandsake]

WOW, thanks for the template

next time I'm in philly, drinks on me! 😀

 

[Taus]

👍

 

[Disciple]

You can basically write,

1. No need for rehab

2. Transfer to acute rehab when medically stable

or

3. D/C to SNF or Nursing Home

Just Kidding...

That's like doing Spine/Pain and writing Dx: Chronic Low Back Pain, LESI X 3, or doing Sports Med and writing Dx: Right Shoulder Strain, PT to eval & treat, Ortho consult.

It's all marketing really. We need to recruit people who will take pride in their specialty.


Also, don't expect the primary service to start carrying out your recommendations. Most of the time it's "That's great, you can do all those things once the patient has been transferred to the rehab floor".

 

[PMR 4 MSK]

You can basically write,

1. No need for rehab

2. Transfer to acute rehab when medically stable

or

3. D/C to SNF or Nursing Home

Just Kidding...

That's like doing Spine/Pain and writing Dx: Chronic Low Back Pain, LESI X 3, or doing Sports Med and writing Dx: Right Shoulder Strain, PT to eval & treat, Ortho consult.

It's all marketing really. We need to recruit people who will take pride in their specialty.


Also, don't expect the primary service to start carrying out your recommendations. Most of the time it's "That's great, you can do all those things once the patient has been transferred to the rehab floor".

Completely agree.

But no one reads the whole surgeon's note. They want to know "Is the surgery service taking the poor schmuck off my hands." In teaching hospitals, turfing is the game. Surgery does the same thing to medicine, hem/onc does it to cards, pulm does it to nephro, peds does it to neuro, etc. Everyone wants less existing patients, some want more new patients to learn from, others just want to get done and go home.

Once you get to private practice, it's quite the opposite. Doctors make a living off patients, and the more on their service, the more they make. Sometimes you gotta pry them off the acute service, other times, they'll come steal your pt from rehab and TF them without telling you. And they will read your note, to see if you have half a brain or know what you are doing. And they will have no problem calling you out for something stupid you write.

 

[Ludicolo]

Just write Dx and ok for transfer to rehab. No one else except your inpt resident reads anything else.

I'm on a trauma surgery rotation right now and ALL my attendings want to hear from PM&R is if/when they will be transferred to rehab.

In teaching hospitals, turfing is the game.

All true. But it doesn’t have to be.

Consult services differ tremendously from academic program to program, even in different institutions within the same program. At one end of the spectrum is the “disposition service” – frustrating, brain numbing, and demoralizing. Learning different criteria and levels of disposition is important, ‘cause it helps to know how the game is played. But to limit our decision making to simply “acute vs. SNF vs. home w/ services” is such a waste of our clinical talents. Even if we make diagnostic/therapeutic recommendations, the primary service disregards them, so we aren’t as eager to see consults the next time, and when we do eventually see them we do substandard work, so those services think even more less of us. Vicious cycle.

At the other end, there are PM&R consult services out there that actually strive to function as the primary musculoskeletal and/or neuromuscular consult service. We’re asked to evaluate a given problem – back pain, joint swelling, progressive weakness – and the recommendations for workup/treatment are actually considered and followed! It’s actually quite inspiring to see. My last couple stints on consults we picked up undiagnosed fractures, DVTs, myasthenia gravis (mistaken for deconditioning), conversion disorder (their working diagnosis was AIDP vs. MS). Even with dispo consults – if you evaluate the patient the way you’re supposed to, you may find things that others have missed.

(Side note to any non-PM&R people who may be lurking here: never order a “STAT” dispo consult at 4pm on a Friday. Not smart, for so many different reasons)

Consults are what you make of them. Problem is, the history and culture of some of the dispo services is so ingrained into the fabric of their institutions – both from the physiatry departments as well as what the other medical/surgical services expect from us - that it can be very challenging for someone to change the status quo. Doesn’t mean we shouldn’t try.

It's all marketing really.

👍

 

[drusso]

Tan's Handbook of PM&R has a nice template.

http://search.barnesandnoble.com/Pr...n/Tan-Jackson-C-Tan-Jackson-C/e/9780815187080

It's a standard Gen Med Consult note with a neuro exam. Include a functional history that addresses ADL's, Mobility, Cognition, Vocational status, etc. For a real exercise in physiatric esoterica, try writing a formal PT RX. Or even better, try writing PT RX for a modality like diathermy with actual dose/frequency parameters. After you do that, go poke yourself in the eye.

 

[TRAMD]

I might be late but: History, ROS, PMH, SH, FH, Exam, Assessment and Recommendations with the following additions from a regular H&P:

History: get a functional history to determine what they could do before and what they needed help with (from people or assistive devices) or couldn't do: transfers, mobility, grooming, bathing, toileting, bowel/bladder, driving, working.

Social history: get a detailed description of their home in terms of stairs and what is on what floor and any other accessibility issues. Get a history of who lives with them and what help they could receive from others in their home or friends and family nearby or willing to move-in or host the patient for a time after discharge.

Assessment: use therapy notes (if you have them) and your own judgement from the history and exam to determine what functionalities are/may be a new issue for this patient since their injury/surgery/stroke and list them in terms of mobility, ADLs and cognition. List other comorbitities that will be barriers to their rehab such as obesity, psych dx, pain, preexisting physical or cognitive deficits.

Recommendations: I look at these things when deciding where a person should go:
1. Are they able to participate in 3 hours of intense therapy daily?
2. Will they benefit from this therapy? I.E. is their condition likely to improve rapidly with intense therapy such that their ability to go home will be higher after a few days to weeks of rehab. The expected improvement can be estimated by knowledge of the natural course of the affliction and the patients current state. A stroke sufferer with grade 2/5 finger extension 3 days after their stroke is a good example of someone likely to show rapid improvement. Answering this question takes reading on expected outcomes and experience on inpatient rehab.
3. Do they have a reasonable discharge plan based on expected outcome and improvement time-course? If this same stroke patient has a capable daughter whom can come live with them for 2-4 weeks after discharge and their home has no stairs...yeah, that's pretty good.
4. Do they have new deficits in at least two areas from mobility, ADLs and cognition?

You then have to think about the options:
1. Home with no therapy - the patient that essentially improved to baseline between when the consult was placed and performed. Rare.
2. Home with outpatient or in-home therapy - this person is likely a yes for the first three but not #4 or has deficits so mild they can still function at home with a little extra help that is available.
3. Acute rehab - this person is a strong yes for all 4 above.
4. Sub-acute rehab - this person is a weaker yes or on the border for #1 and 2. They may not be able to tolerate quite that much therapy or are expected to have a good recovery but with a longer course. They are likely a yes for #3 and 4 with eventual plan of going home or assisted living level of care.
5. Nursing home - Likely a strong no for one or more of #1-3 and yes for #4. Expectations for ever living independently are low.

Finally talk about what areas of rehab should be focused on and any other PM&R area issues (pain, bowel and bladder management, psych issues)