"If it's not documented, it didn't happen."
During a MAC audit, the ONLY evidence that matters is what appears in the medical record. Verbal explanations, staff recollections, or electronic system notes are NOT acceptable. Every element coded on the IRF-PAI must be clearly documented in the patient's medical record.
Pre-Admission Documentation
- Pre-Admission Screening (PAS):Must be signed by rehab physician BEFORE admission date/time. Includes medical necessity justification.
- Acute Care Discharge Summary:From referring hospital with primary diagnosis, procedures, and reason for IRF transfer.
- Physician Orders for Admission:Signed orders for IRF admission with specific rehabilitation services ordered.
Admission Documentation (Day 1)
- Physician H&P:Complete history and physical within 24 hours of admission with specific diagnoses and comorbidities.
- Nursing Admission Assessment:Comprehensive assessment including vital signs, medications, and baseline functional status.
- Therapy Evaluations:PT, OT, and ST (as applicable) evaluations within 3 days of admission with functional scores.
- Admission IRF-PAI:Completed using data from admission assessments (within 3-day assessment window).
First 4 Days Documentation
- IPOC (Individualized Plan of Care):MUST be completed within 4 days of admission. Includes goals, interventions, and IDT team signatures.
- Physician Progress Notes:At least 3 face-to-face visits per week documented with date, time, and clinical findings.
- Therapy Treatment Notes:Daily documentation of therapy sessions with minutes, interventions, and patient response.
Ongoing Stay Documentation
- IDT Meeting Notes:Weekly interdisciplinary team meetings with physician participation documented.
- Therapy Progress Notes:Ongoing documentation of functional progress, barriers, and plan adjustments.
- Nursing Progress Notes:Daily nursing notes documenting patient status, interventions, and response to treatment.
- Physician Orders:All changes to treatment plan must have corresponding physician orders.
Discharge Documentation
- Discharge IRF-PAI:Completed within 2 days before or after discharge using final functional assessments.
- Physician Discharge Summary:Final diagnosis, treatment provided, functional outcomes, and discharge instructions.
- Therapy Discharge Summaries:Final functional scores, progress achieved, and recommendations for continued care.
- Discharge Destination Documentation:Clear documentation of where patient is discharged (home, SNF, acute care, etc.).
Required Elements:
- ✓ Patient name and medical record number on every page
- ✓ Date and time of service
- ✓ Author's name and credentials
- ✓ Legible handwriting or typed notes
- ✓ Signature and date of signature
- ✓ No blank spaces or missing sections
- ✓ Corrections properly made (single line through, initialed)
Unacceptable Documentation:
- ✗ Unsigned or undated notes
- ✗ Illegible handwriting
- ✗ Use of white-out or erasures
- ✗ Backdated entries without explanation
- ✗ Copy-and-paste errors (wrong patient info)
- ✗ Vague or non-specific language
- ✗ Missing required assessments
Error #1: PAS Signed After Admission
Problem: PAS signature date/time is after the admission date/time.
Solution: Ensure physician signs PAS before patient physically arrives. If emergency admission, document exception and obtain physician signature within 24 hours with justification.
Error #2: IPOC Completed After Day 4
Problem: IPOC is completed on day 5 or later, violating the 4-day requirement.
Solution: Set up calendar alerts for day 3 to ensure IPOC is completed by day 4. No exceptions allowed.
Error #3: Insufficient Therapy Minutes Documentation
Problem: Therapy notes don't clearly document 15 hours of therapy in the first 7 days.
Solution: Therapists must document exact start/stop times for each session. Use therapy minute tracking log.
Error #4: Missing Physician Face-to-Face Visits
Problem: Physician progress notes show only 2 visits in a week instead of required 3.
Solution: Track physician visits daily. If physician misses a visit, escalate immediately to ensure compliance.
Error #5: Functional Scores Don't Match IRF-PAI
Problem: IRF-PAI shows different functional scores than therapy evaluation.
Solution: Always use therapy evaluation as the source for functional scores. Cross-check before submission.
For Physicians:
- • Use SPECIFIC ICD-10 codes (avoid unspecified)
- • Document laterality (left vs. right)
- • List all active comorbidities
- • Sign PAS before patient arrives
- • Complete 3+ face-to-face visits per week
- • Attend and document IDT meetings
For Therapists:
- • Document exact start/stop times for therapy
- • Use standardized functional assessment tools
- • Record specific interventions and patient response
- • Complete evaluations within 3 days of admission
- • Document progress toward goals weekly
- • Ensure 15 hours therapy in first 7 days
For Nurses:
- • Complete admission assessment within 24 hours
- • Document all medications and allergies
- • Record vital signs and baseline status
- • Note any changes in patient condition
- • Document patient/family education
- • Ensure discharge planning is documented
For IRF-PAI Coordinator:
- • Review medical record BEFORE coding IRF-PAI
- • Verify all dates and timelines
- • Cross-check every data element
- • Obtain peer review before submission
- • Keep audit trail of sources used
- • Submit within 30 days of discharge