Driving Rehabilitation Pre-Screen

This template is typically used by occupational therapists, rehabilitation teams, clinic staff, or other authorized evaluators who need a structured first-pass screen of driving-related function. It is not a substitute for a formal driver rehabilitation evaluation or an on-road assessment. Use it when you need to document whether a referral is warranted and what areas need follow-up. If your organization has a specific referral pathway, this template helps standardize that decision.

It covers the core domains that often affect driving safety: vision, reaction time and attention, cognition and judgment, and physical function and mobility. It also captures referral basis, current driving status, disposition, and follow-up. It does not replace a full clinical exam, a behind-the-wheel evaluation, or a legal determination of fitness to drive. If you need route-specific driving performance, vehicle controls testing, or licensing decisions, use a more advanced assessment.

It is usually completed when a new concern arises, before referral to driver rehabilitation, or when a patient’s condition changes enough to affect driving safety. Common triggers include a new diagnosis, medication change, recent fall, stroke, vision change, or family concern about driving. It is not meant to be a routine daily inspection. Re-screening is appropriate when the first screen is inconclusive or when the person’s function has changed.

This template supports documentation practices commonly used in rehabilitation, occupational health, and safety programs, but it is not itself a legal standard. The content aligns with general clinical risk screening expectations and can be adapted to local policy, state licensing rules, and provider referral requirements. If your organization follows occupational health or rehabilitation protocols, this form helps create a consistent record of why a driver was referred or cleared for the next step. Final decisions should follow applicable medical, licensing, and employer policies.

A common mistake is recording a vague pass/fail without noting the specific deficit that drove the decision. Another is skipping the referral basis, which makes it hard to explain why the screen was done. Teams also miss documenting whether corrective lenses were available and used, or whether the person’s current driving status was known. This template reduces those gaps by prompting for observable findings and a clear disposition.

Yes. You can tailor the wording for outpatient rehab, inpatient discharge planning, occupational health, or specialty clinics. For example, you may add fields for stroke, dementia, low vision, amputee rehab, or medication effects if those are common in your setting. You can also adjust the disposition options to match your referral network, such as driver rehab, ophthalmology, neurology, or primary care follow-up.

An ad hoc note often misses one or two key domains, which makes it harder to justify a referral or explain why driving concerns were raised. This template forces a consistent walk-through of the major safety factors and makes the outcome easier to review later. It also improves handoff quality when another clinician, family member, or evaluator needs to understand the basis for the recommendation. In practice, it saves time by reducing back-and-forth clarification.

Yes, the template is designed to support referral communication by summarizing the observed concerns and the recommended next step. It works well as a pre-referral record for a driver rehabilitation specialist, physician, or other authorized provider. Before sharing, follow your privacy and consent rules and include only the information needed for care coordination. If your workflow uses an EHR or referral packet, this template can be copied into that process.