Inpatient Stroke Rehabilitation Candidacy Screening Tool
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Inpatient Stroke Rehabilitation Candidacy Screening Tool
Date of Stroke: ___________________
Addressograph
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Rehabilitation Candidacy:
Part I
®
Functional Status: AlphaFIM
Has the patient been observed walking 150 feet?
Yes
No
Please circle score for each item
Eating/Walking
1
2
3
4
5
6
7
Grooming/Bed Transfer
1
2
3
4
5
6
7
Bowel Management
1
2
3
4
5
6
7
Toilet transfer
1
2
3
4
5
6
7
Expression
1
2
3
4
5
6
7
Memory
1
2
3
4
5
6
7
Motor conversion score: ___
Cognitive conversion score: ___
Total FIM score: ___/126
Help Needed: ___ hours
Date Part 1 completed: _______________
Part 2
Ability to Follow Commands:
Yes
No
Date achieved: ____________________
Verbal: “Close your eyes”
Nonverbal: Follows written command “Close your eyes” and/or
Follows addition of gestural cue for “Close your eyes”
Rehabilitation Goals: Does the patient have rehabilitation goals that require inpatient care?
NO
No goals
Appropriate for community rehabilitation services
YES
specify; from your assessment, the patient requires inpatient rehabilitation to improve:
communication
return to oral diet (swallowing)
arm and hand function
self care (bathing, dressing, toileting)
cognitive, perceptual ability
continence (bowel/bladder control)
mobility (transfers, ambulation, sitting with comfort)
ability to perform role (home & money management, organizational, socialization, vocational skills)
caregiver/family‟s ability to manage the patient‟s care after discharge
other: ___________________________________
Date: ____________________
Demonstrates Change:
Yes
No
Date achieved: ____________________
Demonstrates improvement in function over time that is related to rehabilitation goals.
Time over which change will be demonstrated will vary depending on the severity of the stroke.
Verbal Consent to Participate In Rehabilitation:
Yes
No
Date: ________________
Patient/Substitute Decision Maker has agreed to Rehabilitation Goals as identified above and
indicates willingness to participate in rehabilitation intervention post acute care.
“If accepted, would you be willing to participate in rehabilitation services (cite relevant services e.g. PT,
OT, SLP, SW or rehabilitation program) to (cite patient/family goals as listed above) after the doctors feel
you are ready to leave this acute care service?”
Patient meets all candidacy criteria; should be considered for referral to inpatient rehabilitation:
Yes
No
Rehabilitation Readiness:
All qualifying candidates will be followed to determine when rehabilitation readiness is achieved as follows:
Tolerance: Tolerates a minimum of one hour sitting up in a wheelchair (or upright out of bed)
twice per day.
Tolerance achieved:
No
Yes; Date: ________________
Medical Stability:
To guide you in your decision about medical stability, please consider the following:
MRP identifies that patient no longer requires acute care
Cause of stroke explored; medical investigations completed or in process
Secondary prevention/medication plan initiated
Comorbid medical conditions managed/stable
Patient is not palliative (life expectancy > 6 months)
Medical Stability achieved:
No
Yes; Date: __________________
___________________
Readiness Achieved:
No
Yes
Date ready:
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