Plan therapy goals, daily sessions and discharge for each patient across every discipline.

A rehabilitation patient comes with a diagnosis, a limitation and a goal such as walking unaided or feeding without help. A physiotherapist, an occupational therapist, a speech therapist and a doctor each work on a part of that goal.

Progress is measured by scores taken at intervals, and the stay ends with a discharge plan and a home programme. When each therapist keeps a separate notebook, nobody sees the whole picture on the day the team reviews the case.

The rehabilitation physician examines the patient at admission and orders the disciplines needed. Each therapist then performs an assessment, sets short-term goals and writes a timetable of sessions in the gym, the hydrotherapy pool, the speech room or the activities of daily living kitchen.

A day-programme patient arrives by transport at a fixed hour, and an inpatient is wheeled from the ward between sessions. Aides help with transfers and equipment. Therapists note the session done, the exercise level reached and any pain or fall, and a team meeting reviews each patient every week or two.

Equipment is fitted and adjusted along the way: walkers, splints, wheelchairs and orthoses. Social workers meet the family, plan the home visit and arrange follow-up, while billing keeps package charges and part payments.