Post Discharge Medical Review (ABI)

Medical Review Date: [Medical review date] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Method of Review: Telehealth / In person (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Those Present: [Describe who attended the review, e.g., patient, caregiver, family member] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Current Medications: [List all current medications, including names and doses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Current Community/TI Rehabilitation Involvement: [Name of rehabilitation provider and type of input/services received] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Home or Community Support: [Detail any formal or informal home/community support services] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Cognition (e.g., memory, insight, problem-solving, word-finding): [Describe cognitive status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Physical Status (e.g., sensory, motor, olfactory, hearing, vision, speech, swallow, balance, orthopaedic, spasticity, wounds, bladder, bowel): [Provide relevant physical findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Weight / Nutrition: [Comment on weight changes or nutritional concerns] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Seizures: [Details of seizure activity if any] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Pain / Headaches / Sleep Management: [Summarise pain, headache, or sleep-related findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Depression / Anxiety / Mood / Behaviour: [Comment on emotional and behavioural state] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Home Situation / Family or Whānau Concerns: [Describe family dynamics or concerns] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Alcohol / Drug Use: [Detail any substance use] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Work, Learning or Training: [Comment on current engagement in work or education] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Driving: [Details about driving capacity or status] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Medical Certificate: [Note any requested or provided medical certificates] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Community Participation / Fatigue: [Comments on social participation and fatigue levels] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Other: [Include any additional relevant areas] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Recommendations: 1. [Insert recommendation clearly stating who is responsible—e.g., “ABI Doctor to refer to …”] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 2. [Add further recommendations similarly formatted—e.g., “ABI Doctor to contact GP to discuss…”] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never invent patient details, assessments, plans, or interventions—only include information explicitly mentioned in the transcript, notes, or clinical context. If a placeholder does not have associated information, leave it blank. Use bullet points and paragraphs as needed to convey all relevant information from the transcript.)