Presentation to planning

The rehabilitation process is a problem solving process, and this section of the site covers the process from presentation by a patient with a problem to the development of a plan to manage that problem, and others discovered. It must be accepted that a clear temporal distinction between different activities within the process is artificial, because it is likely that all phases are occurring to a greater or lesser extent in most encounters. Nevertheless, it is useful to consider the stages separately, to appreciate how to undertake rehabilitation well. This page introduces the section.

Patients usually present to rehabilitation services with one or more problems. Occasionally a patient either is too impaired (e.g. unconscious) to recognise that there is a problem, or lacks insight or denies there is a problem; other people then present the problems. Usually the first clinician seeing a patients will already have a hypothesis about what the problems are, and their cause and their likely outcomes, before the patient is seen. This impression will arise from the context: the referral information is given in a letter, or phone call, or conversation; and also from other contextual factors (e.g. seeing someone in an intensive care unit or at home).

Nonetheless, though first impressions are often correct in outline, much more information is needed to make decisions and to plan rehabilitation in detail. Collecting, analysing and using the data is a phase of ‘assessment and analysis’, in which various hypotheses concerning the problems and their solutions are explored. It is sometimes referred to as ‘clinical reasoning’ which implicitly includes acquiring data to reason with but does not state the model used to analyse and reason with the information. The model used in rehabilitation is the biopsychosocial model of illness.

The goal of this phase is to achieve a sufficiently sound understanding of the patient’s situation to enable the development of a strategic rehabilitation plan, and to make decisions about immediate or short-term actions.

The process of acquiring, analysing, and formulating data is not undertaken in isolation or in an absolutely logical sequence. Rather it is a series of many re-iterative processes, developing a hypothesis about the situation, such as “he has a right hemiparesis, but he does not have aphasia” and then testing this hypothesis by asking the patient to name objects and follow conditional commands. Among the hypotheses tested may be some relating to treatment, such as “giving baclofen orally will reduce flexor spasticity in the arm“, which can be tested by giving baclofen.

Furthermore, in any more complex case involving two or more team members, different people will be exploring different aspects of the situation, and acquiring different data and confirming or refuting different hypotheses.

The power of a multi-disciplinary team arises from the sharing of information and different overlapping expertise, allowing the generation of a much fuller, more detailed but also more holistic understanding of the situation. This applies whether managing a pandemic, managing the building of a nuclear reactor, or managing a patient with rehabilitation needs.

Therefore it is vital to have a mechanism to share, discuss, and make sense of the totality of information gathered. This may reveal unfilled gaps or areas of inconsistency, and will often also explain findings that are puzzling in isolation but easily understood once in possession of all information.

Though in principle much sharing can be done within documents, whether written or electronic, but a meeting is essential, to allow discussion, questioning, explanation and debate. The end result should be a formulation, an explicit statement that summarises all the important information needed to make and justify subsequent actions and plans.

This section covers the process from first contact through to the setting of goals and agreement on actions.

The component pages are:

Assessment an introduction

This gives a general introduction to the assessment process, emphasising the the collection of data should be driven by the testing of hypotheses about the patient’s situation. It should not be a routine collection of data, the same for every patients. It goal is to increase understanding of the problems so that a programme can be planned. See here.

Patient-centred assessment

This approaches the assessment process from the perspective of the biopsychosocial model of illness, and shows that use of the model requires a person centred approach. It also discusses guidance for undertaking a person centred assessment, with evidence as to its utility. It improves outcome at no extra cost in time. See here.

Analysis

As data are collected, the assessor should be constantly reviewing how the data fit in to what is already known, and whether it raises any new questions to be answered. This section starts with an introductory page, and then has four further ‘child-pages’ exploring the analysis of each patient domain. The first analysis page can be seen here.

Formulation

Formulation is an explicit exposition of the understanding of a patient’s problems – how they arise. what the many interactions are explaining current problems, and what the prognosis is. It should also give options for intervention. The formulation also includes justification for the conclusions reach, The formulation is the foundation on which all plans are built. See more here.

Planning

Not yet written (March 6th 2021)

Setting goals

Not yet written (March 6th 2021)

This page has run through the rehabilitation process up to the point of starting to action. Of course, from first contact intervention occurs – education, trials of therapy, care which involves practicing activities, etc etc. However, in complex cases involving several team meetings, it is wise to have a more formal process of agreeing a formulation of the case, and setting out goals. This process has been dissected, to allow clinicians to improve their practice through illustrating how experienced clinicians think – even if they are no longer aware of the steps and stages occuring.

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