rehabilitatieplan

A rehabilitation plan, known in Dutch contexts as rehabilitatieplan, is a structured, person-centered document developed to restore or maintain functional ability after acute illness, injury, or progressed disability. It aims to coordinate care across disciplines, align goals with the patient’s values, and support independence in daily life and participation in work or school.

Core components include a baseline assessment of physical, cognitive, and psychosocial functioning; clearly defined goals and measurable outcomes; and a description of recommended interventions, timelines, and responsibilities. The plan often combines medical treatment, rehabilitation therapies, environmental adaptations, and social supports.

Development typically involves a multidisciplinary team—physiotherapists, occupational therapists, physicians, nurses, speech and language therapists, and social workers—together with the patient and often family members. Informed consent, shared decision-making, and regular reviews ensure the plan remains relevant as circumstances change.

Common elements also cover risk management, medication review, assistive devices, home modifications, and vocational or educational rehabilitation. Discharge planning and transitions between care settings are integral to prevent regression and support ongoing gains.

Rehabilitation plans are used in hospitals, rehabilitation centers, and home-based care. They reflect local guidelines and can be legally or policy-driven components of broader care plans, with success measured by improved independence, reduced symptoms, and enhanced participation in daily life.