PM&R Inpatient Follow-Up Consultation Note

Date/Time: [Date and time] Hospital Day: [Hospital day]

Location/Unit: [Location/Unit] Primary Service: [Primary team/service]

Attending Physiatrist: [Attending physiatrist name]

Consult Indication: [Brief indication label]

Days Since Initial Consult: [Number] Days Since Last PM&R Note: [Number]

Interval Summary

[Major medical/functional events since last PM&R follow-up; current functional trajectory: [improved / plateaued / declined]; today's key PM&R question; current disposition target] (Limit to 2–4 sentences; emphasize interval change and today's decision points.)

Subjective

[Patient-reported functional changes since last note covering mobility, transfers, gait, ADLs, communication/cognition relevant to participation] (Use "no change" if stable. If patient unable to provide history, state reason and identify alternate historian.)

• Pain: [Location, intensity, character, timing relative to therapy, functional impact, response to current regimen] (Include only if affecting participation. Use "controlled, not limiting therapy" if stable.)
• Spasticity/Tone: [Patient-reported spasms, stiffness, triggers, interference with sleep or therapy] (Include only if relevant.)
• Bowel/Bladder: [Continence, catheter/voiding pattern, bowel regimen tolerance, participation impact] (Include only if relevant.)
• Sleep/Mood/Energy: [Sleep quality, mood symptoms, fatigue, motivation] (Include only if affecting therapy tolerance or safety.)
• Therapy Participation: [PT/OT/SLP involvement, sessions completed/missed with reasons, tolerance, objective progress markers] (Attribute sources: "Per PT/OT/SLP note [date]" or "Per patient.")
• Goals/Preferences: [Patient/family goals or disposition preferences that materially affect the plan] (Include only if discussed today.)

Objective

Vitals/Precautions: [Orthostatic vitals, activity restrictions, weight-bearing status, lines/tubes limiting mobility, isolation status] (Include only items affecting today's rehab decisions.)

Focused PM&R Exam:

• Mental Status/Communication: [Alertness, orientation, attention, command following, communication method, aphasia/dysarthria] (Only elements actually examined today.)
• Motor: [Key muscle groups relevant to mobility/ADLs with MRC grades; lateralization; proximal vs distal pattern] (Avoid exhaustive normal documentation.)
• Tone/Spasticity: [Distribution; Modified Ashworth Scale scores; clonus; triggers; functional impact] (Include only if present or decision-relevant.)
• MSK/Skin: [ROM limitations, joint tenderness, edema; pressure injury location/stage, incisions, device fit] (Only if relevant to mobility or disposition.)

Functional Status (with attribution):

• Bed mobility: [Observed by PM&R / per PT note / per patient report]; [independent / supervision / contact guard / min assist / mod assist / max assist / total assist]; [device/technique]
• Transfers: [Attribution]; [assist level]; [device/technique]
• Gait/Wheelchair mobility: [Attribution]; [distance]; [device]; [assist level]
• ADLs: [Attribution]; [self-care areas with assist levels]; [limiting factors]

Data Reviewed: [Therapy notes with dates and salient findings; pertinent labs impacting rehab safety; imaging relevant to function or precautions; medication trends affecting participation; consultant notes impacting rehab approach or disposition] (List only data that informed today's recommendations.)

Assessment

[Rehabilitation problem representation: 1–3 sentences linking primary condition to key impairments (strength, tone, pain, cognition), activity limitations (transfers, gait, ADLs), participation restrictions (discharge feasibility), and major barriers/facilitators]

1. [Problem]: [Brief descriptor] → [Functional consequence]
2. [Problem]: [Brief descriptor] → [Functional consequence]
3. [Problem]: [Brief descriptor] → [Functional consequence]

(List in order of functional impact. Include only active problems.)

Plan

(Problem-oriented. Specify intervention, responsible party, timeline, and functional rationale. Use "stable, not limiting therapy" for unchanged domains. Omit domains not applicable.)

• Mobility and Therapy Coordination: [Therapy focus areas and goals; barriers and mitigation strategies; safety precautions] – [Responsible party]; [Timeline]
• Pain Management: [Current effectiveness; medication adjustments with functional target; nonpharmacologic strategies] – [Responsible party]; [Timeline] (If opioids: document functional indication and monitoring.)
• Spasticity Management: [Distribution/severity with MAS scores; stretching/positioning program; splinting; medication titration with sedation/falls tradeoffs; focal intervention planning if indicated] – [Responsible party]; [Timeline] (Include only if spasticity affects function.)
• Bowel and Bladder: [Bowel regimen adjustments; bladder plan and catheter strategy; impact on participation] – [Responsible party]; [Timeline]
• Skin Integrity: [Pressure injury location/stage or risk; offloading plan; wound care instructions affecting mobility] – [Responsible party]; [Timeline]
• Equipment and Bracing: [Device/brace; functional indication; inpatient vs discharge use; fit/training needs] – [Responsible party]; [Timeline]
• Other: [Problem-specific recommendations as needed] – [Responsible party]; [Timeline]; [Rationale]

Disposition Recommendation

Recommended setting: [IRF / SNF / LTACH / home with home health / home with outpatient therapy / other]

Supports: [Functional need that cannot be met at lower level; therapy disciplines required and why; medical supervision needs interacting with rehab; participation tolerance evidence]

Barriers to transfer: [Items requiring improvement or resolution before disposition can proceed]

(For IRF: document ability to participate in intensive therapy, need for multiple disciplines, expected measurable improvement, and ongoing physician management needs. If IRF not recommended, briefly state why.)

Follow-Up

Team updates: [Who was updated and key decisions communicated]

Next PM&R follow-up: [Timeframe or trigger-based criteria]

Sign-off criteria: [Conditions under which PM&R will sign off]

Patient/family education: [Topics covered] (Include only if performed today.)