Rehab Prescription Care Plan Template

Key objectives

To provide patients with a digital eRehabilitation Prescriptions following discharge from hospital after a serious injury.

The eRehabilitation Prescription is part of a 3-step discharge process, helping trauma patients leaving hospital to better manage their aftercare.

It includes:

  • eRehabilitation Prescription – a tailored care plan informing patients about what has happened to them and signposting support services to give advice about commonly confronted problems.

  • Discharge consultation – a detailed consultation conducted in collaboration with patients and their specialist healthcare professional (i.e. trauma practitioner and pharmacist) before leaving hospital.

  • Two-week follow-up phone call / ongoing access and online consultation via Patients Know Best – to reinforce the contents of the eRehabilitation Prescription and move forward using online consultations and remote monitoring.


Outcome measures

  • To register a patient on PKB and pre-populate the demographics and appointments in PKB.

  • To use a standards-based approach to enable the solution to be reused with other PHRs.

  • Share care plan via third-party systems using PKB's API's.


Current Baselines

Patients left the acute hospital with no care plan, no documentation of their stay or treatments and primary care wasn't alwaysinformation of the acute hospital admission.

“Our feedback told us that patients, and sometimes their families or carers, felt like they’d been ‘forgotten’ once they left the hospital and there really was no sort of care plan in place to help with that.”


Workflow


  1. Patient: Claim their PKB record

  2. Team: Add carer to the record

  3. Carer: Claims PKB record and views patients record

  4. Team: Adds care plan and diary entry to the patients PKB record

  5. Carer: Views patients PKB record

  6. Team: Discharges patient with complete history in their PKB record

  7. Team: Share Rehab prescription care plan with third party system via PKBs APIs

  8. Patient: Views history of stay and rehab care plan

  9. Third party systems: Views patients care plan and data in the PKB record

Rehab Prescription Care Plan Template

“If you have a patient that comes in with a head injury and they have short-term memory loss, they can’t always retain the information they’re being told. By using Patients Know Best, it means that when going home or to a local hospital, the information is there and can be reiterated and utilised when needed.”

Example care plan template code for Rehab Prescription Care Plan HTML

<div class="form-inline">

<style media="screen">

.form-group {width: 100%; !important}

.border {background-color:#ffffff; padding: 5px;border-bottom: 1px solid #a9a9a9;"}

</style>

<style media="print">

.calendar_icon {display: none; !important}

.border {background-color:#ffffff; padding: 5px;"}

.footer-team-img {display: none; !important}

</style>

<div class="print">

<div class="row" style="background-color:#0D475D; padding: 5px;">

<div class="col-sm-12">

<p><strong style="color: #ffffff;">Outstanding Needs:</strong></p>

</div>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-12">

<label for="dischargeDate1"></label>

Transfer/Discharge Date

<input class="form-control" type="text" name="dischargeDate1" id="dischargeDate1"></input>

<input class="calendar_icon" type="image" src="/images/button_calendar.png" onclick="displayDatePicker('dischargeDate1', this, 'dmy', '/');return false;"></input>

<br />

<textarea class="form-control" rows="10" name="ongoing_procedures" style="width:100%;">Actions for GP:


Actions for next care provider:


Action for patient:


Rehabilitation:</textarea>

</div>

</div>

</div>

<div style="margin-top:15px;">

<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-6">

<label for="Kin">Next of kin:</label>

<input type="text" name="Kin" id="Kin" class="form-control" ></input>

</div>

<div class="col-sm-6">

<label for="Kin_contact">Next of Kin contact number:</label>

<input type="text" name="Kin_contact" id="Kin_contact" class="form-control"></input>

</div>

<hr />

</div>

<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="GP">GP and address:</label>

<input type="text" name="GP" id="GP" class="form-control"></input>

</div>

<div class="col-sm-4">

<label for="current_loc">Current location:</label>

<input type="text" name="current_loc" id="current_loc" class="form-control"></input>

</div>

<div class="col-sm-4">

<label for="MTC">MTC:</label>

<input type="text" name="MTC" id="MTC" value="Southmead Hospital" class="form-control"></input>

</div>

<hr />

</div>


<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="consultant">Lead Consultant: </label>

<input type="text" name="consultant" id="consultant" class="form-control"></input>

</div>

<div class="col-sm-8">

<label for="professional_contacts_invovled">MTC contacts</label>

<textarea class="form-control" rows="3" name="professional_contacts_invovled" id="professional_contacts_invovled" style="width: 100%;" placeholder="ie, physio, OT, SALT, MHLT"></textarea>

</div>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-8">

<label for="mtcoordinator">Major Trauma Coordinator</label>

<input type="text" name="mtcoordinator" id="mtcoordinator" class="form-control" style="width: 100%"></input>

</div>

<div class="col-sm-4">

<label for="mtcoordinator">Telephone number:</label>

<input type="text" name="mtcoordinatorTel" id="mtcoordinatorTel" class="form-control" style="width: 100%" value="01174 141 546"></input>

</div>

</div>

</div>

<div style="margin-top:15px;">

<div class="row rounded-top" style="background-color:#0D475D; padding: 5px;">

<div class="col-sm-12">

<p><strong style="color: #ffffff;">Pre-injury information</strong></p>

</div>

</div>

<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="past_med_history">Significant past medical history</label>

</div>

<div class="col-sm-8">

<textarea rows="6" name="past_med_history" id="past_med_history" style="width:100%;" class="form-control"></textarea>

</div>

<hr />

</div>


<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="social_support">Social support</label>

</div>

<div class="col-sm-8">

<textarea rows="6" name="social_support" id="social_support" style="width:100%;" class="form-control"></textarea>

</div>

<hr />

</div>


<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="environment">Housing/home environment</label>

</div>

<div class="col-sm-8">

<textarea rows="6" name="environment" id="environment" style="width:100%;" class="form-control"></textarea>

</div>

<hr />

</div>


<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="workOptions">Work/vocation/roles</label>

</div>

<div class="col-sm-8">

<select class="form-control" name="workOptions" id="workOptions">

<option value="--">Select </option>

<option value="Full/PT Education">Full/PT Education</option>

<option value="Employed">Employed</option>

<option value="Unemployed">Unemployed</option>

<option value="Childcare/Carer">Childcare/Carer</option>

<option value="Retired">Retired</option>

<option value="Other">Other</option>

</select>

<textarea rows="6" name="vocation" style="width:100%;" class="form-control"></textarea>

</div>

<hr />

</div>


<div class="row border-bottom" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="Leisure">Leisure</label>

</div>

<div class="col-sm-8">

<textarea rows="6" name="Leisure" id="Leisure" style="width:100%;" class="form-control"></textarea>

</div>

<hr />

</div>


<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-4">

<label for="func_status">Functional Status <br/> Mobility, transfers, ADLs</label>

</div>

<div class="col-sm-8">

<textarea rows="6" name="func_status" id="func_status" style="width:100%;" class="form-control"></textarea>

</div>

</div>

</div>

<div style="margin-top:15px;">

<div class="row hidden-xs hidden-sm" style="background-color:#0D475D; padding: 5px;">

<div class="col-sm-6">

<p><strong style="color: #ffffff;">Date and Mechanism of injury</strong></p>

</div>

<div class="col-sm-6">

<p><strong style="color: #ffffff;">Date of admission</strong></p>

</div>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-6">

<p class="visible-xs visible-sm"><strong>Date and Mechanism of injury</strong></p>

<input type="text" name="mechanissmate1" class="form-control"></input>

<input class="calendar_icon" type="image" src="/images/button_calendar.png" onclick="displayDatePicker('mechanissmate1', this, 'dmy', '/');return false;"></input>

<textarea class="form-control" rows="6" name="Mechanism_of_injury" style="width:100%;"></textarea>

</div>

<div class="col-sm-6">

<p class="visible-xs visible-sm"><strong>Date of admission</strong></p>

<input type="text" class="form-control" name="admissionDate1"></input>

<input class="calendar_icon" type="image" src="/images/button_calendar.png" onclick="displayDatePicker('admissionDate1', this, 'dmy', '/');return false;"></input>

</div>

</div>

</div>

<div style="margin-top:15px;">

<div class="row" style="background-color:#0D475D; padding: 5px;">

<label for="cp_descriptionInjury"><strong style="color:#ffffff;">Description of Injury</strong></label>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<textarea class="form-control" name="cp_descriptionInjury" id="cp_descriptionInjury" rows="10" style="width: 100%;"></textarea>

</div>

</div>


<div>

<div class="row" style="background-color:#0D475D; padding: 5px;">

<p><strong style="color: #ffffff;">Ongoing Rehabilitation Needs</strong></p>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="col-sm-6">


</div>

<div class="col-sm-6">

<p><i>Optional to select category</i></p>

</div>

</div>


<div class="row border">

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Specialist inpatient" name="cp_inpatient" id="cp_inpatient"> Specialist inpatient</input>

</div>

</div>

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Category A" name="cp_category_a" id="cp_category_a"> Category A</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Category B" name="cp_category_b" id="cp_category_b"> Category B</input>

</div>

</div>

</div>


<div class="row border">

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Specialist outpatient" name="cp_outpatient" id="cp_outpatient"> Specialist outpatient</input>

</div>

</div>

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Multidisciplinary" name="cp_multidisciplinary" id="cp_multidisciplinary"> Multidisciplinary</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Single Discipline" name="cp_singleDiscipline" id="cp_category_b"> Single Discipline</input>

</div>

</div>

</div>


<div class="row border">

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Non-specialist outpatient" name="cp_nonSpecIpatient" id="cp_outpatient"> Non-specialist inpatient</input>

</div>

</div>

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Category C" name="cp_category_c" id="cp_category_c"> Category C</input>

</div>

</div>

</div>


<div class="row border">

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Community Rehabilitation" name="cp_commRehab" id="cp_commRehab"> Community Rehabilitation</input>

</div>

</div>

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Specialist MDT" name="cp_specialistMDT" id="cp_specialistMDT"> Specialist MDT</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Generic MDT" name="cp_genericMDT" id="cp_genericMDT"> Generic MDT</input>

</div>

</div>

</div>


<div class="row border">

<div class="col-sm-6">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="No Ongoing Rehabilitation Needs" name="cp_noRehabNeeds" id="cp_noRehabNeeds"> No Ongoing Rehabilitation Needs</input>

</div>

</div>

<div class="col-sm-6">


</div>

</div>


<div class="row" style="background-color:#ffffff; padding: 5px;">

<p><strong>Onward Referral for rehabilitation</strong></p>

<input class="form-control" type="text" name="onwardRehabDate1" id="dischargeDate1"></input>

<input class="calendar_icon" type="image" src="/images/button_calendar.png" onclick="displayDatePicker('onwardRehabDate1', this, 'dmy', '/');return false;"></input>

<br />

<textarea class="form-control" rows="3" name="cp_onwardReferral" style="width:100%;"></textarea>

</div>


<div class="row" style="background-color:#ffffff; padding: 5px;">

<label for="cp_apptsExpect"><b>What appointments should you expect after discharge:</b></label>

<textarea class="form-control" name="cp_apptsExpect" id="cp_apptsExpect" rows="6" style="width: 100%;" placeholder="Enter details of appointment date and time, if known."></textarea>

</div>


<div class="row" style="background-color:#ffffff; padding: 5px;">

<label for="cp_lookFor">What you and your carer/family should look out for:</label>

<textarea class="form-control" name="cp_lookFor" id="cp_lookFor" rows="3" style="width: 100%;"></textarea>

</div>


<div class="row" style="background-color:#0D475D; padding: 5px;">

<div class="col-sm-12">

<p><strong style="color: #ffffff;">Rehabilitation needs checklist</strong></p>

</div>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<p><strong>Physical impairment requiring rehabilitation</strong> </p>

<select class="form-control" name="cp_impairmentYN">

<option value="--">Please select</option>

<option value="Yes">Yes</option>

<option value="No">No</option>

</select>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Brain injury with prolonged disorder of consciousness (PDOC i.e. vegetative or minimally concious state)" name="cp_brainInjury1" id="cp_brainInjury1"> Brain injury with prolonged disorder of consciousness (PDOC i.e. vegetative or minimally concious state)</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Brain injury without prolonged disorder of consciousness" name="cp_brainInjury2" id="cp_brainInjury2"> Brain injury without prolonged disorder of consciousness</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Tracheostomy weaning" name="cp_tracheostomyWeaning" id="cp_tracheostomyWeaning"> Tracheostomy weaning</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Spinal cord injury - ventilated" name="cp_spinal1" id="cp_spinal1"> Spinal cord injury - ventilated</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Spinal cord injury - Not ventilated" name="cp_spinal2" id="cp_spinal2"> Spinal cord injury - Not ventilated</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Spinal fractures - no neurology" name="cp_spinal3" id="cp_spinal3"> Spinal fractures - no neurology</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Single complex fracture or dislocation" name="cp_singleComplex" id="cp_singleComplex"> Single complex fracture or dislocation</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Multiple fractures" name="cp_multipleFracture" id="cp_multipleFracture"> Multiple fractures</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Amputee" name="cp_amputee" id="cp_amputee"> Amputee</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Brachial plexus injury/peripheral nerve injury" name="cp_brachialPlexus" id="cp_brachialPlexus"> Brachial plexus injury/peripheral nerve injury</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Chest trauma" name="cp_chestTrauma" id="cp_chestTrauma"> Chest trauma</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Other" name="cp_physImpOther" id="cp_physImpOther"> Other</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Facial injuries (inc visual loss)" name="cp_facialInjury1" id="cp_facialInjury1"> Facial injuries (inc visual loss)</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Thorax (inc ribs, lungs, diaphragm, sternum)" name="cp_ThoraxInjury1" id="cp_ThoraxInjury1"> Thorax (inc ribs, lungs, diaphragm, sternum)</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Abdomen and Pelvis" name="cp_abdomenInjury1" id="cp_abdomenInjury1"> Abdomen and Pelvis</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Upper limb: single complex fracture or dislocation" name="cp_singleFractureInjury1" id="cp_singleFractureInjury1"> Upper limb: single complex fracture or dislocation</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Upper limb: multiple fractures" name="cp_multipleFractureInjury1" id="cp_multipleFractureInjury1"> Upper limb: multiple fractures</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Upper limb: limb reconstruction" name="cp_limbReconstructionInjury1" id="cp_limbReconstructionInjury1"> Upper limb: limb reconstruction</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Upper limb: amputee" name="cp_amputeeInjury1" id="cp_amputeeInjury1"> Upper limb: amputee</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Lower limb: single complex fracture or dislocation" name="cp_singleFractureInjury2" id="cp_singleFractureInjury2"> Lower limb: single complex fracture or dislocation</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Lower limb: Pelvic Fracture" name="cp_pelvicFractureInjury1" id="cp_pelvicFractureInjury1"> Lower limb: Pelvic Fracture</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Lower limb: Multiple fractures" name="cp_multipleFractureInjury2" id="cp_multipleFractureInjury2"> Lower limb: Multiple fractures</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Lower limb: Limb reconstruction" name="cp_limbReconstructionInjury2" id="cp_limbReconstructionInjury2"> Lower limb: Limb reconstruction</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Lower limb: Amputee" name="cp_amputeeInjury2" id="cp_amputeeInjury2"> Lower limb: Amputee</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Nerve injury (inc brachial/lumbar plexus, peripheral nerve)" name="cp_nerveInjury1" id="cp_nerveInjury1"> Nerve injury (inc brachial/lumbar plexus, peripheral nerve)</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="External (inc burns, lacerations, degloving)" name="cp_externalInjury1" id="cp_externalInjury1"> External (inc burns, lacerations, degloving)</input>

</div>

</div>


<div class="row" style="background-color:#ffffff; padding: 5px;">

<p><strong>Cognitive or mood disturbance requiring rehabilitation</strong> </p>

<select class="form-control" name="cp_cognitiveYN">

<option value="--">Please select</option>

<option value="Yes">Yes</option>

<option value="No">No</option>

</select>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Communication difficulties" name="cp_commDiff" id="cp_commDiff"> Communication difficulties</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Cognitive difficulties" name="cp_cogDiff" id="cp_cogDiff"> Cognitive difficulties</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Challenging behaviour" name="cp_challengingBehaviour" id="cp_challengingBehaviour"> Challenging behaviour</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Mental Health difficulties pre-injury" name="cp_preinjuryMH" id="cp_preinjuryMH"> Mental Health difficulties pre-injury</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Mental Health difficulties post injury" name="cp_postinjuryMH" id="cp_postinjuryMH"> Mental Health difficulties post injury</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Emotional difficulties" name="cp_emoDiff" id="cp_emoDiff"> Emotional difficulties</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Other" name="cp_cogOther" id="cp_cogOther"> Other</input>

</div>

</div>


<div class="row" style="background-color:#ffffff; padding: 5px;">

<p><strong>Psychosocial issues (that may impact rehabilitation)</strong> </p>

<select class="form-control" name="cp_psychoYN">

<option value="--">Please select</option>

<option value="Yes">Yes</option>

<option value="No">No</option>

</select>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Housing/accomodation" name="cp_houseAcc" id="cp_houseAcc"> Housing/accomodation</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Drug/alcohol misuse" name="cp_drugAlc" id="cp_drugAlc"> Drug/alcohol misuse</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Complex medico-legal issues including best interest decisions, safeguarding and DOLS" name="cp_medicoLegal" id="cp_medicoLegal"> Complex medico-legal issues including best interest decisions, safeguarding and DOLS</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Educational" name="cp_Educational" id="cp_Educational"> Educational</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Referred to violence reduction team" name="cp_violence" id="cp_violence"> Referred to violence reduction team</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Vocational/job role requiring specialist vocational rehabilitation" name="cp_vocational" id="cp_vocational"> Vocational/job role requiring specialist vocational rehabilitation</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Other" name="cp_psychoOther" id="cp_psychoOther"> Other</input>

</div>

</div>

<div class="form-row">

<label for="cp_rehabPrescDev">Has the Rehabilitation Prescription been developed with the involvement of the patient and/or their family/carer?</label>

<select class="form-control" name="cp_rehabPrescDev" id="cp_rehabPrescDev">

<option value="--">Select</option>

<option value="Yes">Yes</option>

<option value="No">No</option>

<option value="Not Appropriate">Not Appropriate</option>

</select>

</div>

<div class="form-row">

<label for="cp_rehabPrescDiscuss">Has the Rehabilitation Prescription been discussed with the patient where possible?</label>

<select class="form-control" name="cp_rehabPrescDiscuss" id="cp_rehabPrescDiscuss">

<option value="--">Select</option>

<option value="Yes">Yes</option>

<option value="No">No</option>

<option value="Not Appropriate">Not Appropriate</option>

</select>

</div>

<div class="row" style="background-color:#ffffff; padding: 5px;">

<label for="cp_patientComments">Patient Comments</label>

<textarea class="form-control" name="cp_patientComments" id="cp_patientComments" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<h3>The Rehabilitation Prescription has been distributed to:</h3>

<div class="form-row">

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Other" name="cp_distributionGP" id="cp_distributionGP"> GP</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Other" name="cp_distributionProvider" id="cp_distributionProvider"> Next care provider</input>

</div>

<div class="form-check">

<input class="form-check-input" type="checkbox" value="Other" name="cp_distributionPatient" id="cp_distributionPatient"> Patient</input>

</div>

</div>

<h3>You can use your personal diary to log your questions and thoughts. This will not be read unless you so request.</h3>

<h2>Assessed by:</h2>

<div class="form-row">

<label for="cp_assessedByName">Name:</label>

<input type="text" name="cp_assessedByName" id="cp_assessedByName" class="form-control"></input>

<label for="cp_assessedByProfession">Profession:</label>

<input type="text" name="cp_assessedByProfession" id="cp_assessedByProfession" class="form-control"></input>

</div>

<h2>RP Completed by:</h2>

<div class="form-row">

<label for="cp_rpName">Name</label>

<input type="text" name="cp_rpName" id="cp_rpName" class="form-control"></input>

<select class="form-control" name="cp_rpTitle" id="cp_rpTitle">

<option value="--">Select</option>

<option value="Consultant in Rehabilitation Medicine">Consultant in Rehabilitation Medicine</option>

<option value="Specialist Trainee in Rehabilitation Medicine">Specialist Trainee in Rehabilitation Medicine</option>

<option value="Band 7 Specialist clinician">Band 7 Specialist clinician</option>

<option value="Major Trauma Coordinator">Major Trauma Coordinator</option>

</select>

</div>

</div>