Real IRF-PAI Form Completion Walkthrough

Step-by-step guide to completing an IRF-PAI assessment using a sample patient case

Sample Patient: Margaret Thompson
72-year-old female admitted with left-sided stroke

Patient Demographics

  • Name: Margaret Thompson
  • DOB: 03/15/1952 (Age: 72)
  • Gender: Female
  • Medicare ID: 123-45-6789A
  • Admission Date: 11/15/2025
  • Admission Time: 14:30

Clinical Summary

  • Primary Diagnosis: Ischemic stroke, left MCA (I63.512)
  • Onset Date: 11/10/2025
  • Transferred From: Memorial Acute Hospital
  • Presenting Symptoms: Right hemiparesis, aphasia
  • Rehab Potential: Good

Active Comorbidities

  • • Hypertension (I10) - on metoprolol
  • • Type 2 Diabetes (E11.9) - on insulin
  • • Atrial fibrillation (I48.91) - on warfarin
  • • Dyslipidemia (E78.5) - on atorvastatin

Functional Status on Admission

  • • Requires moderate assist for transfers
  • • Maximal assist for ADLs
  • • Unable to ambulate independently
  • • Expressive aphasia present
  • • Alert and oriented x3

Step-by-Step IRF-PAI Completion

Final IRF-PAI Completion Checklist

All demographic information matches Medicare card and acute hospital records

FIM scores match PT, OT, SLP, and nursing documentation

Primary diagnosis matches acute hospital discharge diagnosis with medical evidence

All comorbidities have active treatment with physician orders and documentation

Comorbidity tier assignment is accurate based on CMS guidelines

60% Rule qualification verified (stroke = qualifying condition)

Assessment completed within 3-day window (by 11/18/2025)

Interdisciplinary team reviewed and approved all scores

No discrepancies between IRF-PAI and medical record

IRF-PAI Coordinator final review completed before submission

✓ IRF-PAI Ready for Submission

This assessment demonstrates best practices for zero-fault accuracy and MAC audit prevention.