Inpatient Rehabilitation Psychology Consult Note

Date/Time of Service: [Date and time of encounter]

Author: [Clinician name, credentials]

Patient: [Full name], [DOB], [MRN]

Unit/Service: [IRF unit or rehabilitation service]

Consult Request

Requesting clinician/discipline: [Name, role/discipline]

Date consult received: [Date] | Urgency: [routine / urgent / stat]

Reason for consult: [Succinct reason stated by referrer in one sentence]

Working consult question: [Operationalized consult focus framed as a functional rehab question] (Include if initial referral question was unclear; note clarification efforts.)

Chief Concern

[1–2 sentences framing why rehabilitation psychology is involved now, stated as a functional rehabilitation problem. Include a brief patient quote if it adds clarity.]

Sources of Information

[Patient interview, chart review, therapy notes, nursing notes, family/collateral contacts, team input] (List sources actually used.)

Reliability limitations: [Communication barriers, delirium, sedation, limited historian, interpreter use] (Only include if significant limitations affect confidence; otherwise omit.)

Medical/Rehab Context

[Reason for IRF admission, index event, and brief timeline. Current rehab day. Medical factors relevant to psychological/behavioral presentation: pain, sleep disruption, CNS-active medications, isolation precautions. Current functional constraints shaping recommendations: mobility, communication, sensory limitations, endurance.] (Keep concise; do not duplicate full medical history.)

Presenting Problems: Barriers to Rehabilitation Participation

(Include only barrier domains identified during evaluation. For each domain, describe evidence, functional impact on rehabilitation, and modifiable targets. Omit domains with no identified barrier.)

[Barrier Domain]

Evidence: [Observed or reported findings with precipitating/maintaining factors]

Functional impact: [How this barrier affects therapy participation, persistence, carryover, or safety]

Modifiable targets: [Specific intervention targets]

(Repeat barrier domain subsection for each identified barrier. Common domains include: Mood and Adjustment; Anxiety or Trauma Responses; Motivation and Values Alignment; Pain, Fatigue, and Sleep Interference; Cognition and Communication; Behavioral Dysregulation; Environmental or System Factors; Family and Caregiver Dynamics.)

Participation Snapshot

[Typical engagement pattern over last 24–72 hours: attendance, tolerance, refusal patterns with context, need for redirection, carryover between sessions, safety incidents] (Include if relevant pattern data available.)

Relevant History

• Psychiatric: [Prior diagnoses, treatments, hospitalizations; history of suicide attempts or violence when relevant to current risk]
• Substance use: [Substances, frequency, last use, withdrawal risk] (Include if applicable.)
• Psychosocial: [Living situation, supports/caregivers, occupation/roles, cultural/spiritual factors relevant to coping and engagement]
• Baseline cognition: [Prior TBI, dementia, learning differences, baseline functional level] (Include if relevant.)

(If history unknown but clinically important, note "unable to obtain" with plan for collateral.)

Current Subjective Report

Patient-reported concerns: [Mood, anxiety, sleep, pain interference, fears, perceived barriers to therapy]

Patient goals: [Stated functional goals; what matters most to patient—independence, returning home, family roles, work] (Link to engagement strategies.)

Objective Findings

Behavioral Observations

[Arousal/alertness, cooperation, effort, initiation, persistence, frustration tolerance, cue responsiveness, observed triggers and de-escalation responses]

Mental Status Examination

• Appearance: [Description]
• Behavior: [Description]
• Speech: [Rate, rhythm, volume, prosody]
• Mood (stated): [Patient's words]
• Affect (observed): [Range, congruence, reactivity]
• Thought process: [linear / goal-directed / circumstantial / tangential / disorganized]
• Thought content: [SI/HI, delusions, obsessions—document only phenomena assessed]
• Perceptions: [Hallucinations if assessed] (Omit if not assessed.)
• Orientation: [person / place / time / situation]
• Attention: [Grossly intact / impaired with description]
• Memory (gross): [Immediate, recent, remote]
• Insight: [intact / partial / limited]
• Judgment: [intact / fair / limited]

Cognitive Screening

[Instrument(s) used, score(s), and interpretation in functional terms. Note accommodations and validity concerns.] (If no formal screening, document informal bedside tasks and observed performance.)

Risk and Safety Assessment

(Required when within scope of consult. If patient cannot participate, document reason, collateral sources used, interim safety steps, and plan for reassessment.)

Suicide/Self-Harm Risk

Ideation: [present / absent] | Plan: [present / absent] | Intent: [present / absent] | Behaviors: [History of attempts, self-injury, or none]

Risk factors: [Relevant clinical, historical, and situational factors]

Protective factors: [Internal and external supports]

Overall risk level: [low / moderate / high] — [Brief justification]

Mitigation plan: [Monitoring level, safety planning, means safety, psychiatric referral, environmental modifications]

Violence/Aggression Risk

Findings: [Threats, aggression during hospitalization, impulsivity, identified triggers]

Safety recommendations: [Staff approach, environment, contingency plan]

(Include only if assessed.)

Other Rehab-Relevant Safety Risks

[Elopement/wandering, falls related to impulsivity or poor safety awareness, delirium-related risk] (Include only if applicable.)

Capacity Assessment

Decision evaluated: [Specific decision in question]

Understanding: [Findings] | Appreciation: [Findings] | Reasoning: [Findings] | Expressing choice: [Findings]

(Include only if capacity questioned for a specific decision.)

Assessment and Formulation

[Biopsychosocial synthesis linking medical condition → cognitive/emotional/behavioral mechanisms → observed rehab barriers → modifiable targets. Address interaction effects where relevant.]

Diagnoses/Clinical impressions: [DSM/ICD diagnoses with qualifiers: provisional, rule out, features consistent with] (Do not diagnose solely from chart labels without confirming criteria.)

Conditional prognosis for participation: [What changes would likely improve engagement]

Recommendations and Plan

(Concrete, actionable, interdisciplinary. Begin each recommendation with imperative verb. Specify who, what, when, and how to gauge response.)

Therapy Teams (PT/OT/SLP)

• [Learning principles, cueing strategies, communication supports]
• [Graded exposure approach for feared tasks]
• [Reinforcement strategies with defined criteria]
• [Session timing, rest breaks, pacing parameters]

Nursing

• [Sleep hygiene interventions, orientation cues]
• [Consistent behavioral responses across staff]
• [Overstimulation reduction during vulnerable periods]
• [Pain/anxiety coping prompts]

PM&R/Physician Team

• [Consider evaluating for: delirium, medication side effects, sleep/pain optimization, withdrawal risk]
• [Medication timing relative to therapies if indicated]

Case Management/Social Work

• [Family meeting needs, caregiver training]
• [Outpatient referrals: psychology, neuropsychology, community resources]
• [Discharge environment and support assessment]

Family/Caregivers

• [Communication strategies, validation approaches]
• [Supporting therapy carryover at bedside/home]

Interventions Provided This Encounter

[Supportive therapy, psychoeducation, motivational interviewing, relaxation training, coping skills] (Describe briefly without detailed process content.)

Follow-Up Plan

[Planned frequency while in IRF or criteria-based follow-up] (If one-time consult: No scheduled follow-up; team may re-consult if new concerns arise.)

Communication to Requesting Team

[Method: verbal update / interdisciplinary conference / secure message / documented in chart. Include recipients and timing.] (Required for consult documentation. If pending, note planned communication and timeframe.)