PM&R Acute Care Consultation Note

Date/Time: [Date and time of consult]
Location: [Hospital unit/bed]
Consulting Service: PM&R
Referring Service: [Referring team/service]
Consult Question(s): [Verbatim consult question(s) from order]
Information Sources: [Sources used: patient / family or caregiver name and relationship / chart / therapy notes with dates / nursing / case management / interpreter and language if used] (State reliability limitations explicitly, e.g., "History limited by [reason]" or "Patient intubated; history per [source]." If key collateral was unavailable: "Collateral unavailable at time of consult; will re-attempt.")

Reason for Consult

[Brief purpose of consult and specific questions to be answered, e.g., disposition level, therapy tolerance, rehabilitation needs, equipment] (Limit to 1–3 lines.)

Clinical Context

(Brief, problem-focused summary including only items that affect rehabilitation participation, precautions, or discharge planning. Do not restate the full H&P.)

• Primary diagnosis/event: [Diagnosis/event with onset date]
• Key procedures: [Procedure(s) with dates]
• Medical stability factors: [Oxygen support / hemodynamics / dialysis / infection or isolation status / active lines or drains] (Include only if relevant.)
• Activity restrictions and diet: [Weight-bearing status / spinal or hip precautions / other precautions / diet and swallowing status]

Prior Level of Function and Home Environment

(Document baseline function before this illness/injury using standardized assist levels. Attribute each statement to a source. If unknown, state explicitly.)

• Mobility (baseline): [Ambulation distance, device, assist level: Independent / Supervision / Contact Guard / Min Assist / Mod Assist / Max Assist / Dependent] — [Source]
• Transfers (baseline): [Bed, chair, toilet transfers with assist level] — [Source]
• ADLs (baseline): [Bathing / dressing / toileting / feeding with assist levels] — [Source]
• Cognition/communication (baseline): [Orientation, memory, communication] — [Source]
• Bladder/Bowel (baseline): [Continence status and management] — [Source]
• Prior DME/orthotics: [Existing devices/orthoses] — [Source]
• Home environment: [Dwelling type; entry/internal stairs with number and rails; bathroom setup; bedroom location; caregiver availability and capability; transportation access] (If unknown: "Home setup not yet verified—recommend case management obtain details." Include when home discharge is being considered.)
• Patient goals/preferences: [Direct patient quote if it affects disposition planning]

Current Functional Status

(Time-anchor all data with source and date. Use measurable descriptors and standardized assist levels. Do not infer abilities without observation or documented therapy data. If the patient cannot be assessed, state why.)

• Mobility and Transfers:
  • [Bed mobility: assist level and technique] — [Source, date]
  • [Sit-to-stand: assist level, device] — [Source, date]
  • [Transfers: bed-to-chair/toilet; assist level and device] — [Source, date]
  • [Gait: distance, device, assist level; vital sign response if relevant] — [Source, date]
  • [Wheelchair mobility: propulsion distance, assist level] — [Source, date] (Include if primary mode.)
  • [Stairs: number of steps, rails, assist level] — [Source, date] (Include if attempted.)
• ADLs: [Feeding / grooming / dressing / toileting with assist levels] — [Source, date]
• Cognition/Communication: [Orientation; attention; safety awareness; command-following; aphasia if present] — [Source, date]
• Swallowing/Diet: [Current diet level; aspiration precautions; feeding route if applicable] — [Source, date]
• Participation/Tolerance: [Minutes tolerated per session; rest break needs; limiting symptoms: pain / orthostasis / dyspnea / fatigue / agitation; behavioral factors] — [Source, date]
• Safety Concerns: [Fall risk features; delirium; neglect; lines/tubes limiting mobility] — [Source, date]

Rehab-Relevant Medical History

(Include only conditions that affect rehabilitation tolerance, safety, or disposition. Omit if no relevant findings.)

• Neurologic impairments: [Weakness pattern; sensation; spasticity/tone; neglect]
• Pain: [Current regimen; adequacy; sedation effects]
• Bowel/Bladder: [Dysfunction and current management]
• Skin integrity: [Pressure injury risk; wounds; flap precautions]
• Sleep/Mood: [Issues affecting therapy participation]
• Sensory impairments: [Vision/hearing deficits affecting therapy]

Physical Examination

• General: [Alertness; positioning; distress level]
• Cardiopulmonary: [Work of breathing; exercise tolerance constraints]
• Musculoskeletal: [ROM limitations; contractures; joint stability; surgical sites; pain with movement]
• Neurologic: [Mental status; cranial nerves if relevant; strength by key muscle groups; sensation; coordination; tone/spasticity with Modified Ashworth if applicable; reflexes if relevant; neglect]
• Skin: [Pressure areas; wound/incision summary]
• Equipment: [Assistive device or orthosis fit issues if observed]
• Pertinent vitals/labs/imaging: [Items influencing rehab safety with dates; orthostatic vitals if symptomatic] (Include only if relevant to rehab.)

Assessment

[Synthesis of diagnosis; key impairments; activity limitations in mobility/ADLs; participation restrictions; contextual factors including home setup and supports; and medical complexity affecting rehabilitation]

Rehab Potential: [Good / Fair / Poor] — [Brief rationale and expected trajectory]

Barriers to Rehabilitation:

• [Barrier] — [Modifiable / Non-modifiable]; [Mitigation plan if modifiable]

Plan

Disposition Recommendation

[Primary recommendation: IRF / SNF / Home] (Use language "Medically appropriate for [level] level of care"; do not comment on acceptance or coverage.)

[Explicit justification based on current function, therapy tolerance, medical needs, safety, and available supports]

• If IRF: [Therapy disciplines needed: PT / OT / SLP]; [Anticipated ability to tolerate 3 hours daily: Yes / No / With rest breaks]; [Need for physician oversight]; [Measurable functional goals]; [Estimated length of stay]
• If SNF: [Skilled nursing and therapy needs]; [Expected therapy frequency and tolerance]; [Why IRF intensity is not appropriate]
• If Home: [Supervision level and accessibility requirements]; [Home health or outpatient services]; [DME required]; [Caregiver training needs]
• Contingency: [Alternate pathway if clinical status changes or primary plan is not feasible] (Include if uncertainty exists.)

Acute Care Therapy Prescription

• PT: [Frequency]; [Priorities: gait training / transfers / balance / endurance]
• OT: [Frequency]; [Priorities: ADL training / energy conservation / safety / caregiver training]
• SLP: [Frequency]; [Priorities: dysphagia management / communication / cognition] (Include only if applicable.)
• Safety parameters: [BP/HR/O2 thresholds]; [Weight-bearing and other precautions]; [Nursing mobility recommendations with assist level and device]

DME and Orthotics

• [Device or equipment] — [Medical/functional rationale]; [Training needs]; [Needed at discharge / Anticipate later]
• [Orthosis] — [Indication and wear schedule]; [Skin checks]; [Training needs]

Rehab-Linked Medical Management

(Include only when PM&R is making specific recommendations. Coordinate high-risk changes with primary team.)

• Pain optimization: [Non-sedating regimen; dose timing before therapy]
• Spasticity/tone: [Stretching; medications; focal treatments]
• Bowel regimen: [Schedule; stool softener/stimulant]
• Bladder management: [Voiding trial / catheter plan; PVR monitoring]
• Sleep/delirium prevention: [Non-pharmacologic measures; day-night cues]
• Skin and positioning: [Pressure injury prevention; turning schedule; cushion/mattress; limb positioning]

Care Coordination

• Interdisciplinary communication: [Summary of discussions with primary team, therapy, nursing, case management]
• Family/caregiver communication: [Participants; topics; decisions]
• Pending actions: [Authorizations; equipment orders; home assessment; therapy re-evaluations]
• Follow-up plan: [When PM&R will reassess; triggers for re-consult]
• Service plan: [PM&R will continue to follow / Sign off]