Evaluation and review

At the end of each treatment encounter with a patient, the clinician will automatically and briefly review what has happened. The information will rarely be enough to alter, radically, the existing formulation, goals or the actions still planned. Teams also need to take stock and review matters. However, teams work at a different scale. They are more focussed on the whole situation. rather than a restricted part of the whole. They also necessarily work in a different scale of time. Nonetheless, the team, just like an individual clinician need to evaluate and review matters from time-to-time.

Meetings to evaluate matters are very variable. At one end, with a low level of input and a clinical state that is stable or changing in a predicted and predictable way, a short telephone or in-person discussion once every six months may be sufficient. At the other end, a complex in-patient whose clinical state is changing fast and where prediction is difficult, a full meeting might be needed within four weeks. Although urgent team meetings may occur, most should be planned in advance.

The content of a rehabilitation planning review meeting is illustrated in the graphic. It is essentially covering the same ground as the initial rehabilitation planning meeting, but the time spent on each aspect may be very different. One important practical matter is for the meeting to be well documented. In complex cases it is often difficult to discover what happened, let alone when it happened. Therefore all significant events since the previous meeting should be documents as part of the record.

The meeting will have one of three general outcomes: continuation, transfer on to another rehabilitation service, or discharge from the service. They are shown in this graphic. The process of transfer (i..e. discharge from this rehabilitation service) is considered in the next, and last part of this section.

The main message is that review meetings should be planned, should be proportional to the situation, and must be documented, including a restatement (or revision) of the formulation and long-term goals, and including a description of any major events or changes, and of the patient’s situation at the time.


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