ADL FUNCTIONAL / REHABILITATION POTENTIAL RAP

Patient / Resident: ____________________________________ Date: _____________________

Rehabilitation and /or restorative plans are suggested if one or more are present. Check triggers present.
TRIGGERS: Rehabilitation Triggers ___ Bed Mobility Not Independent
___ Transfer Not Independent ___ Walk in Room Not independent ___ Walk in Corridor Not independent ___ Locomotion on unit Not independent ___ Locomotion off Unit Not independent ___ Dressing Not independent ___ Eating Not independent ___ Toilet Use not independent ___ Personal Hygiene Not independent ___ Bathing Not independent ___ Resident believes s/he is capable of some increased independence in at least some ADLs. ___ Staff believe resident capable of increased independence of at least some ADLs.

Confounding problems may require resolving to improve function. CHECK triggers present from MDS.
GUIDELINES: ( ) Delirium ( ) Persistent Mood problem ( ) Decline in mood ( ) Daily behavioral symptoms ( ) Decline in behavior ( ) Unstable or acute health problem (see J5a, b) ( ) Psychoactive Medication Use ( ) Status has deteriorated since last assessment Clarifying issues to be considered: ( ) Ability to make decisions ( ) Prior improvement in cognition, mood, ADLs or behavior. ( ) Impaired communication ability ( ) Impaired visual function ( ) Has difficulty in balance ( ) Has functional limitation in R.O.M. ( ) Staff believe resident could be more independent ( )Resident believes s/he could be more independent
Complete ADL supplement Part 1 for all triggered residents (in Resident Assessment Instrument Manual). Residents with rehabilitation potential should have ADL supplement Part 2 completed.

Maintenance Triggers ___ Severely impaired decision making (Note: When both maintenance and rehabilitation triggers are present, maintenance takes precedence.)

Other Factors:

ADL FUNCTIONAL / REHABILITATION POTENTIAL RAP

RAP SUMMARY: Nature of the Problem: Complications and Risk Factors: : Need for Referrals to Appropriate Health Care Providers:

Factors Considered in Developing Care Plan Interventions:

========================================================================== ___Condition Requires ___Improvement ___ Maintenance ___Risk of ___Symptom Relief Intervention of Function Decline or Palliation ___ New Care Plan ___Revision of Care Plan __Continuation of Care Plan ___Will Not Care Plan

=========================================================================== If Not Proceeding With Care Plan, Explain Why:

Location of Information:

Completed by:_

Date: