Multidisciplinary rehabilitation assessment template and sample
A rehabilitation assessment template that gathers each discipline's admission findings into one record, with sample entries for each section.
✓Function across six rehab domains
✓Sample entries for each section
✓Ends with family-agreed priorities
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What's inside
Reason for Referral and Rehabilitation Priorities
Medical and Social History
Assessment Information and Sources
Current Function by Domain
Risks and Safety
Equipment and Environment
Team Summary
Agreed Rehabilitation Priorities
+ 2 more sections
Preview · 10 sections
Multidisciplinary Rehabilitation Assessment
Patient
Patient ID
Date of birth
Assessment date
Therapy
Therapist
Languages
Referred by
Reason for Referral and Rehabilitation Priorities
Reason for referral
Patient and family priorities
Medical and Social History
Relevant medical history
Social and home situation
Pre admission function
Assessment Information and Sources
Assessment methods and sources
Current Function by Domain
Domain
Current Function
Assistance Needed
Team Member
Notes
Mobility and transfers
Self-care and daily living
Communication and swallowing
Cognition
Psychosocial wellbeing
Community and vocational
Risks and Safety
Identified risks
Equipment and Environment
Equipment and home environment
Team Summary
Team summarySummarize explicit findings from each discipline.
Agreed Rehabilitation Priorities
Priority
Lead Discipline
Target Date
Recommendations and Referrals
recommendations
referrals
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Reason for Referral and Rehabilitation Priorities
Quote the referral question, then the patient's priorities and the family's, kept separate.
More guidance
Copy the referral question as the referrer wrote it, then record the patient's own priorities separately from the family's. The two often differ, and both matter at goal setting. If the patient has communication or cognitive difficulties, note how you gathered their view, for example yes/no questions, pointing to pictures, or a relative translating, so later readers know how directly it reached you.
2
Medical and Social History
Note the medical facts that change rehab, then who lives at home and who cares.
More guidance
Keep the medical history to what changes rehab: relevant conditions, precautions the medical team has set, medicines that affect alertness or balance, and hearing or vision. Spend more words on the social picture: who lives at home, who will do the daily caring, which floor the person sleeps on, the toilet type, stairs, work, and the languages spoken at home. In joint families the relative who attends meetings is often not the one who will help at 2 am.
3
Assessment Information and Sources
List every assessment, observation, record and conversation this document draws on, with dates.
More guidance
List every source the document draws on: each discipline's assessment with its date, observations on the ward or in the gym, the hospital discharge summary, and conversations with family. Where a team member used a published functional measure, record its name, the date and the result as its manual reports it, and keep the completed form in that discipline's file. A reader should be able to trace any statement back to where it came from.
4
Current Function by Domain
Describe what the person did in each domain, how much help, and who saw it.
More guidance
Write one or two lines per domain in functional terms: what the person did, how much help they needed, and in what conditions. “Needs assistance” tells the next reader nothing. “Needs one person to steady at the hips for sit-to-stand from the bed” tells them how to help tonight. Name the team member who observed it so questions reach the right person, and write “not yet assessed” rather than leaving a domain to guesswork.
5
Risks and Safety
List each identified risk, who identified it, and what is already in place.
More guidance
List each risk the team has identified, who identified it, and what is already in place. Typical rehab entries are falls, swallowing safety at meals, skin, leaving the ward unaccompanied, low mood, and carer strain. Copy precautions exactly as the responsible clinician confirmed them, without softening or extending them. If a risk triggered a clinic policy such as safeguarding, note that the policy was followed and where the full record is kept.
6
Equipment and Environment
Record equipment owned, used on the ward and needed at home, plus the home layout.
More guidance
Record the equipment the person already owns, what they use on the ward, and what home will need. For Indian homes, note whether the toilet is Indian-style or Western, whether the person sleeps on a bed or on the floor, threshold steps, narrow bathroom doors, and space for a wheelchair to turn. Photos or a rough floor plan from the family help; note that they exist rather than describing every room.
7
Team Summary
Bring each discipline's findings together; clinical impressions stay with the clinician who signs them.
More guidance
Bring together what each discipline found without adding conclusions that nobody has stated. Two or three sentences per area usually work: where the main barriers to the patient's priorities lie, and which findings more than one discipline noticed. Where team members saw different things, such as steadier walking in the gym than on the ward at night, report both with their conditions. Clinical impressions belong to the clinician who formed them and should be signed by that person.
8
Agreed Rehabilitation Priorities
Three to five priorities the family has agreed, each with a lead and target date.
More guidance
Keep this to three to five priorities that the patient and family have heard and agreed, each with a lead discipline and a realistic target date. The lead coordinates that priority; other disciplines still contribute. These priorities become the headings of the interdisciplinary goal plan, so phrase them as outcomes the patient would recognise. If they have not yet been discussed with the family, label them as team proposals.
9
Recommendations and Referrals
Write programme recommendations and outside referrals as actions with an owner and date.
More guidance
Recommendations here concern the programme itself: which disciplines, how often, and what still needs assessing. Referrals go to people outside the team, such as a dietitian, orthotist, wheelchair service or psychiatrist, with the reason and the name of the person sending the referral. Write each as an action someone can carry out by a date.
Multidisciplinary rehabilitation assessment template and sample: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Reason for Referral and Rehabilitation Priorities
Referred by Dr K. (neurologist) for inpatient rehabilitation after hospital discharge. Mr S. said, with his son translating, that he wants to “walk to the temple at the end of our lane again”. His wife's priority is managing the bathroom at night without waking the household.
Medical and Social History
Before admission: walked alone indoors and to the local market (about 10 minutes) without an aid; bathed himself; kept the accounts for the family shop. Lives with wife, son, daughter-in-law and two grandchildren in a first-floor flat, 18 stairs, no lift. Home languages: Tamil, some English.
Assessment Information and Sources
PT assessment 3 March (gym and ward). OT bathroom and kitchen assessment 4 March. SLT communication and bedside swallowing assessment 3 March. Nursing admission checklist. Hospital discharge summary dated 28 February. Family interview with wife and son, 4 March, in Tamil.
Current Function by Domain
Mobility and transfers: stands from the bed with one person steadying at the hips; walks 10 metres in the corridor with a quad stick and close supervision, stopping twice to rest. Observed by PT, 3 March.
Risks and Safety
Falls: two near-falls at home in the last month, both at night on the way to the toilet. In place: bed lowered, call bell within reach, commode beside the bed overnight (agreed with nursing, 3 March).
Equipment and Environment
Owns a folding walker, unused since the hospital stay. Home bathroom has an Indian-style toilet and a 15 cm step at the door. Son will send photos of the bathroom and stairs to the OT.
Agreed Rehabilitation Priorities
Priority: manage the bathroom at night with his wife's help. Lead: OT. Target date: before the home visit in week 3.
Recommendations and Referrals
Refer to orthotist for an ankle-foot orthosis review. PT (Mr D.) to send the referral by 6 March.
Team rehab assessment vs single-discipline assessment
Team rehab assessment
Single-discipline assessment
Who writes it
Key worker or coordinator, with entries from every discipline
One therapist
Purpose
A shared starting point for team goal setting
Detailed findings for one discipline's plan
Level of detail
Key functional findings per domain
Full test results and observations
Ends with
Three to five priorities agreed with the family
Discipline goals and recommendations
Read by
The whole team, the patient and the family
That discipline, its supervisor and the referrer
Tips and mistakes to avoid
Do
Set a deadline for each discipline's entries, such as day three, so the summary is ready for goal setting.
Record home languages and who interprets; a son translating for a parent may shorten the patient's words.
Ask early who will be the main carer after discharge, and whether they also work.
Use the same six domains in every rehab document so change over time is easy to read.
In healhab, clinics author their own templates in Template Studio, so a centre can reuse this structure for every admission.
Avoid
Pasting each discipline's full assessment into the shared record instead of summarising and pointing to it.
Recording only the family's priorities because the patient has aphasia or tires quickly.
Writing “needs help” without saying what help, from how many people, and where.
Calling priorities agreed when the family has never heard them.
About this assessment report
A multidisciplinary rehabilitation assessment brings each discipline's admission findings into one record: why the person was referred, how they managed before, current function across mobility, self-care, communication, cognition and mood, risks, equipment, and the priorities the team and family agree. This free template is structure only, with no test items.
Admitting a patient to inpatient or day rehab
Starting outpatient neuro rehab with three or more disciplines
Re-assessing someone who returns after a gap
Preparing for the first goal-setting meeting with family
Read more
Most rehab admissions produce four or five separate assessments, one per discipline. This template sits above them as the single record the team reads before goal setting. Each discipline still completes its own detailed assessment (in US settings, the evaluation).
The key worker or rehab coordinator usually opens it on admission and completes it over the first few days. It records what the team observed and what the patient and family want, and leaves clinical conclusions to the clinicians who make them.
Questions
What is a multidisciplinary rehabilitation assessment?+
It is the shared admission record for a rehab team. Each discipline assesses in its own way, then adds key findings to one document covering history, function by domain, risks, equipment and agreed priorities.
Who should complete a team rehab assessment?+
One named person, usually the key worker or rehab coordinator, owns the document and chases missing entries. Each therapist and the nurse in charge write their own domain rows, and the clinician leading the episode reviews the team summary.
How soon after admission should it be finished?+
Most teams finish it before the first goal-setting meeting, often within the first week of an inpatient stay. Set the timeline in your centre's procedure and date each section as it is completed.
Is this the same as a rehab admission form?+
An admission form captures personal details, consent and medical information on day one. This assessment comes after the team has seen the patient and records function and priorities. Many centres use both.
Can we add our own functional measures?+
Yes. In Assessment Information and Sources, record the measure's name, the date and the result as its manual reports it. Keep the completed form in the discipline file; the template itself has no test items.
Does the template include a diagnosis or prognosis?+
No. It records observed and reported function. Medical details come from the treating doctor's records, and any clinical impression is written and signed by the responsible clinician.
Is there a filled sample of this assessment?+
Yes. Each section guide on this page shows a fictional sample entry, using initials only. The Team Summary has no sample, because that wording belongs to the clinicians who formed the findings.
