Tips to help providers meet new IRF documentation and coverage requirements
HIM Connection, March 2, 2010
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Ensure documentation of the post-admission physician evaluation. The post-admission evaluation should identify any relevant changes that have occurred since the preadmission screening. It should also include a documented history and physical exam and a review of the patient’s prior and current medical and functional conditions and comorbidities.
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Keep admission orders. At the time of admission, a physician must generate admission orders that stay in the patient’s medical record at the IRF.
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Retain the IRF patient assessment instrument (PAI). The IRF-PAI must also be included in the patient’s medical record at the IRF. The IRF-PAI must correspond with all of the other information in the patient’s IRF medical record.
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