Documenting Physician Services

The physician is the ONLY member of the team that can justify both medical and rehab necessity for admission and continued stay. Key areas for physician documentation include:

History and Physical

  • Integrate the acute hospital picture, the IRF pre-assessment and all consults done before admission
  • Demonstrate active comorbidities and medical reasons for monitoring or managing care
  • Describe the functional limitations and document the goals for each functional deficit—not just ambulation (18 FIM items, not 1)
  • Outline the plan of care, multi-disciplinary team…
  • Establish goals for the stay
  • Establish foundation for IRF level of care (e.g., why not in skilled care, home health, or outpatient)

Progress Notes

  • Speak to rehab progress (not just patient impressions)
  • Speak to assessment and evaluation of medical conditions, for example:

“COPD, limiting sitting/standing tolerance, and ADL completion, required systemic steroids in acute care, currently improving. Will continue MDIs and following peak flows/O2 sats and need for therapy escalation. Nursing rpt. Pt initiating dressing tasks, but requires assist to complete. Therapy cont. to monitor O2 sats before & after activities/exercise, increase challenge if O2 > or = 90.”

The Discharge Summary

  • Summarize medical and rehab information
  • Restate the central issues of rehabilitation needs, medical monitoring and treatment
  • Restate why this level of care was appropriate
    • Medical gains
    • Functional gains (FIM items)
    • Patient/family discussions & education
  • Document discharge status and follow up plan

Other Physician Documentation Needed

  • Review/signature rehab plan of care
  • Review/signature on preadmission information and appropriateness of admission
  • Lead team conference and review/signature approval team conference notes
  • When two or more physicians on the case –one physician has to integrate key points from other physicians into documentation of the “whole” patient.
  • Review & signature approval
    • Preadmission review documentation
    • Team conferences
    • Treatment Plan
    • Orders: Services, Frequency, and Duration
    • Orders: “Hold” and “Resume” therapy




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