Template instructions

The following template has been used to provide an example of how to record a client’s rehabilitation plan. 

When reading the templates, please note:

• each client goal is numbered e.g. Client Goal 1
• each step corresponding to a particular client goal is numbered in relation to that goal e.g. 1a), 1b)
• each action plan corresponding  to a particular step is numbered in relation to the step e.g. 1a), 1b).

On subsequent TABS two sample plans using the template have been provided.  The first includes a progress report on a previous plan. The second presents the next stage of rehabilitation. 

• The First Example documents the client’s goal and his progress over the plan period towards the achievement of his goal, each of the steps and whether each element of the action plan was completed.  Note in Step 1a), even though Jack has only partially achieved his home exercise program, he has still been able to achieve his step of safely ascending and descending a flight of 16 stairs independently.  In contrast to this, even though Jack has achieved all of the elements of his action plan 1c), he has only partially achieved step 1c) - performing all aspects of his personal hygiene independently.  This discrepancy between the two indicates that something unaccounted for has prevented him achieving the step.  Discussion with Jack revealed that his mother has been helping him shower at home; he is also fearful of falling in the shower.  New steps and action plans were written to accommodate those issues that were identified since the previous plan.

• The Second example documents the follow-on plan, which lists subsequent steps and the action plans to achieve them. 

Example 2

Tips: Plan Prompt questions and considerations

Client Goal

1. Is the goal SMART, client centred and useful for rehabilitation? Does it clearly describe how the client will benefit from recommended action plan? If you are unsure, use the SMARTAAR Goal Worksheet to revise goal statement.
2. Does the goal appear to reflect client identified priorities?
3. Is there information regarding level of client engagement? Client generated or client focused goal?
4. How realistic is the goal given your knowledge of the nature and impact of the client’s injuries and their progress to date?

Client Steps

1. Is the step (a goal statement) SMART, client centred and useful for rehabilitation? Does it clearly describe how the client will benefit from recommended action plan? If you are unsure, use the SMARTAAR Goal Worksheet to revise goal statement in relevant step.
2. Does the step appear to reflect client identified priorities / needs? Steps may often be client focused rather than client generated – has the level of client engagement been reported?
3. How realistic is the step given your knowledge of the nature and impact of the client’s injuries and their progress to date?
4. Consider, if the client can perform all the steps, will they successfully achieve their goal? Are there additional steps needed? Ensure all steps contribute to achievement of this goal (and each goal they are described for).
5. Do steps describe what the client will be able to do as a consequence of the action plan? If no, should it be an action?
6. If too many steps are needed per goal, does the goal need to be broken into more than one goal?

Action Plan

1. Are ALL recommended actions you think are necessary for the client to achieve their steps and goal included? This includes services for which funding is requested and other actions which don’t need separate funding e.g. referrals, request for GP to consider allied health plan for mother’s counselling, ADHC funded services, client and family actions including home programs. Ensure actions are related to each step. Are all necessary? Do others need to be added?
2. Are level of services requested and level of steps and goal well matched? Consider appropriateness of service (cost, clinical consensus, evidence base), appropriateness of provider (relevance, availability), expected degree of benefit to client. Have alternatives been considered but discounted -explain?
3. If the actions are extensive (high level type and amount of services), should the step be broken down into more than one step?
4. Are the actions consistent with available evidence, clinical practice and guidelines?
5. Is there information the client has agreed to / collaborated in developing the action plan?
6. If too many actions are needed per step, does the step need to be broken into more than one step?

Rehab Plan as a whole

1. Does overall plan tell a cohesive story about how recommended actions will address clinical needs and support client to achieve steps and goals?
2. Is the level of client engagement in the report described? If goal and step are client focused and different from client generated priorities, e.g. because client lacks insight and goal is not realistic in given time frame, is this recorded in the report (somewhere?)
3. When funding for services is requested, is there information that describes how this is related to the nature and impact of their injuries? When requested services are for other people e.g. family, describe how the client will benefit from these services and why this is an injury related request for the client. When assessing funding requested services is it clear how the client will benefit? Do the requested services meet scheme specific funding criteria?
4. Is the type and intensity of services requested in line with:
   o the desired level of change in the client in the specified time frame as described in steps and goals?
   o criteria for funding as relevant?
5. Does the plan describe client’s progress with actions, steps and goals to date, including issues affecting progress and how these will be addressed? Does the plan describe reasons for variations in projected action plan and impact on client progress towards steps & goals?
6. Consider whether number of goals and steps in whole plan reflects realistic rehabilitation plan for specified period.