IRF Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check
Brief Description
Physician/Non Physician Practitioner (NPP) order
History and Physical reports (include medical history and current list of medications)
Discharge Summary from hospital or other facility
Preadmission screening/notes
Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care
Practitioner, nurse, and ancillary progress notes
  • Medical necessity for IRF
  • Support minimum required face to face visits
  • Nutrition notes
  • Treatment records
  • Vital signs and weight
IRF PAI (Patient Assessment Instrument)
  • Documentation to support information
Interdisciplinary Team Conference notes
  • Names and professional credentials of participants
Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
PT/OT/SLP
  • Initial evaluation
  • Plan of care
  • Treatment encounter notes
  • Therapy minutes log
  • Discharge summary
Medication Administration Record (MAR) and/or Infusion Flowsheet documenting the quantity administered include a dose, route, and frequency given
Vital sign records, weight sheets, and treatment records
Itemization of services
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Facility process of how electronic signature is created if using electronic health record

Additional Resources

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Inpatient Rehabilitation Facility (IRF) webpage for additional information and resources.

Last Updated Jun 18 , 2024

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.