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The pre-admission screen must be reviewed and approved by a rehabilitation physician before admission to an inpatient rehabilitation facility. Once the patient is admitted, a physician must evaluate the pre-admission screening information and verify that the patient’s condition has remained the same. Any changes in the patient’s medical or functional condition must be documented. In an IRF setting, a physician will attend to the patient at least three times per week to assess goals and progress. Beginning October 1, 2018, the post-admission physician evaluation is counted as one of the three required face-to-face rehabilitation physician visits in the first week of the stay. 

The physician’s role is to orchestrate the individualized plan of care and facilitate the interdisciplinary approach through weekly team meetings. Direction for all of this activity begins with the admission assessment documented via the history and physical (H&P). The H&P is a key component of justifying the “reasonable and necessary” criteria for IRF admissions. It substantiates the need for active, ongoing therapeutic intervention by multiple, coordinated therapy disciplines and specialized medical and nursing approaches.

The H&P is now a lengthy document that includes comprehensive information. Much of the information can be gleaned from a proper pre-admission screening assessment and “imported” into the H&P, so to speak. In addition, a well-designed H&P form can guide the process of writing a thorough assessment. It usually begins with the basic data: date and time, referring physician and hospital, primary care physician, informant and a list of what records were reviewed. The next most important pieces of information are the chief complaint and primary diagnosis. These should be written with a coder in mind and in terms of rehabilitation specific impairments and related etiologic diagnosis that will be considered in the 60% rule, when applicable.

The next critical section of the H&P is the History of Present Illness. It begins with a specific onset date of the disease, disorder or injury (or current exacerbation) and tells a story of how this event has impacted the individual’s ability to experience the things that make their life meaningful. It includes a narrative description of current medical issues and status and a list of all active comorbidities impacting the impending rehabilitation program. All of the information that follows (medical/surgical history, review of systems, physical exam, functional assessment, plan of care, etc.) will provide the details, but this area on the H&P presents the “Executive Summary” of what will follow. The History of Present Illness sets the stage for individualizing the plan of care based on the persons’ prior level of functioning and the effects of their current problems.