Clinical Documentation Best Practices

What nurses and therapists need to document for accurate IRF-PAI coding and compliance

The Three Required Criteria for Every Comorbidity
ALL THREE must be documented for a comorbidity to count toward tier assignment
1

Physician Documentation

Comorbidity must be documented by physician (MD, DO, NP, PA) in H&P, progress note, or consultation note

✅ What to Document:

  • • Date of physician documentation
  • • Specific diagnosis with appropriate detail (not vague terms)
  • • Physician name and credentials

❌ What Doesn't Count:

  • • Nurse or therapist notes alone
  • • "History of" conditions (unless currently active)
  • • Diagnoses from previous hospitalizations without current physician confirmation
2

Active Treatment During IRF Stay

Patient must receive ongoing treatment for the comorbidity during rehabilitation stay

✅ Examples of Active Treatment:

  • • Medications: "Patient on Lasix 40mg daily for CHF"
  • • Monitoring: "Daily weights and I&O monitoring for fluid status"
  • • Labs: "BMP checked q3 days to monitor renal function"
  • • Treatments: "Nebulizer treatments q4h for COPD exacerbation"
  • • Dietary: "2g sodium diet for CHF management"
  • • Therapy modifications: "Oxygen during therapy for respiratory support"

❌ What Doesn't Count as Active Treatment:

  • • Condition mentioned but no treatment given
  • • Treatment discontinued before IRF admission
  • • "Continue home medications" without specifying what they're for
3

Clinical Impact on Rehabilitation or LOS

Comorbidity must affect therapy participation, progress, or length of stay

✅ Examples of Clinical Impact:

  • • "COPD limits therapy tolerance - requires frequent rest breaks"
  • • "CHF exacerbation delayed therapy progression due to dyspnea"
  • • "Diabetes management requires glucose checks before each therapy session"
  • • "Wound care for pressure ulcer extends LOS by 3 days"
  • • "Anemia (Hgb 7.2) causes fatigue, limiting therapy participation to 30 min sessions"
  • • "Acute kidney injury requires dialysis schedule coordination with therapy"

❌ What Doesn't Show Impact:

  • • "Patient has hypertension" (no impact described)
  • • "Patient on medications" (doesn't explain how it affects rehab)
  • • Generic statements without specific examples

CRITICAL: All Three Required

If ANY of the three criteria is missing, the comorbidity CANNOT be coded for IRF-PAI. Missing documentation = lost reimbursement and potential audit risk.

What Nurses Should Document
Nursing documentation provides evidence of active treatment and clinical impact

Medications & Treatments

✅ Good: "Lasix 40mg PO given at 0800 for CHF management. Daily weight 165 lbs (down 2 lbs from yesterday). I&O: +500mL. Lungs clear, no edema."

❌ Poor: "Medications given as ordered."

Vital Signs & Monitoring

✅ Good: "Blood glucose 180 mg/dL pre-breakfast. 4 units Humalog given per sliding scale. Glucose rechecked before therapy at 1000: 145 mg/dL. Patient cleared for therapy."

❌ Poor: "Blood sugar checked."

Clinical Impact on Therapy

✅ Good: "Patient required 2L O2 during therapy due to COPD. Therapy session limited to 30 minutes due to dyspnea and fatigue. SpO2 88% on room air, improved to 94% on 2L."

❌ Poor: "Patient on oxygen."

Wound Care & Skin Integrity

✅ Good: "Stage 3 pressure ulcer on sacrum, 4cm x 3cm x 1cm depth. Wound care performed with Aquacel dressing change. Wound prevents supine positioning during therapy, requiring side-lying modifications."

❌ Poor: "Wound care done."

What Therapists Should Document
Therapy documentation shows how comorbidities affect rehabilitation progress

Therapy Tolerance & Modifications

✅ Good: "Patient's COPD exacerbation limits activity tolerance. Required 3 rest breaks during 45-min PT session. SpO2 dropped to 88% with ambulation, improved with rest and 2L O2. Gait training modified to shorter distances."

❌ Poor: "Patient has COPD."

Functional Impact

✅ Good: "Patient's severe anemia (Hgb 7.0) causes significant fatigue. Unable to complete full OT session - tolerates only 20 minutes before exhaustion. ADL training limited to essential tasks only."

❌ Poor: "Patient fatigued."

Progress Delays

✅ Good: "Patient's acute CHF exacerbation on Day 3 resulted in 2 days of missed therapy due to dyspnea and medical management. Progress toward discharge goals delayed by approximately 3-4 days."

❌ Poor: "Patient missed therapy."

Safety Precautions

✅ Good: "Patient's diabetes requires glucose monitoring before each therapy session. Session delayed 15 minutes today due to hypoglycemia (glucose 65). Patient given juice, rechecked at 95, then cleared for therapy."

❌ Poor: "Patient has diabetes."

Interactive Documentation Scenarios
Test your understanding of documentation requirements
1

Situation: Patient has Type 2 Diabetes documented in H&P

Question: What additional documentation is needed for IRF-PAI coding?

2

Situation: Nurse notes: 'Patient has CHF'

Question: Is this documentation sufficient for IRF-PAI?

3

Situation: Patient on Lasix 40mg daily, no other CHF documentation

Question: Can you code CHF based on medication alone?

4

Situation: Therapist notes: 'Patient has COPD per history'

Question: Is this adequate physician documentation?

5

Situation: Patient has 'history of MI' in H&P from 5 years ago

Question: Can this be coded as a current comorbidity?

Key Takeaways for Clinical Staff
  • Be specific: "Patient on Lasix 40mg for CHF" is better than "Patient on medications"
  • Show impact: Explain HOW the comorbidity affects therapy, not just that it exists
  • Document daily: Active treatment must be documented throughout the IRF stay
  • Use numbers: Include lab values, vital signs, measurements to show objective evidence
  • Connect the dots: Link comorbidity → treatment → impact on rehab in your documentation