Affix patient label if available

AROC v3 New Zealand DATA COLLECTION FORM
Need for Interpreter Service
1. Interpreter needed
2. Interpreter not needed
Total Leave Days ___________________________________
Total rehabilitation treatment suspension days __________
Total rehabilitation treatment suspension occurrences ____
Suspension of Treatment Unplanned
1. Yes
2. No
Co-morbidity present – interfering with rehabilitation episode
1. Yes
2. No
Co-morbidities interfering with rehabilitation Episode
1. Ischaemic heart disease 8. Depression 15. Epilepsy 22. Delerium
2. Cardiac failure 9. Bipolar affective disorder 16. Parkinsons 23. Morbid obesity
3. Atrial fibrillation 10. Drug and alcohol abuse 17. CVA 99. Other
4. Osteoporosis 11. Dementia 18. Spinal cord injury/disease
5. Osteoarthritis 12. Asthma 19. Visual impairment
6. Upper limb amputation 13. CAL/COPD 20. Hearing impairment
7. Lower limb amputation 14. Renal failure 21. Daibetes
Complications Interfering with Rehabilitation Episode
1. No complications
2. UTI 7. Significant electrolyte imbalance
3. Pressure Ulcer 8. Falls
4. Wound infection 9. Faecal impaction
5. DVT/PE
6. Chest infection 99. Other
Date multi-disciplinary team rehabilitation plan established _________________________
Date discharge plan established __________________________________________
Episode End Date ____________________________________________
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