IRF Admission History & Physical

Date/Time of Service: [Date and time of IRF H&P]

Admission Date/Time: [IRF admission date and time]

Primary Rehab Diagnosis: [Primary rehabilitation diagnosis with impairment category and laterality]

Etiologic Diagnosis and Onset Date: [Etiologic diagnosis, onset date, and key procedures]

Precautions/Restrictions: [Weight-bearing status / Spine precautions / Fall risk level / Aspiration precautions / Isolation status / Seizure precautions] (Include only those that apply; if not yet determined, state "Pending evaluation")

Communication Considerations: [Aphasia / Dysarthria / Cognitive-communication deficit / Hearing impairment / Vision impairment / Interpreter needed / None] (Specify type and accommodations needed)

IRF Admission Rehab Summary

[One-sentence executive summary of why patient is admitted to IRF, including diagnosis and current rehab needs]

• Primary rehab diagnosis: [Diagnosis with impairment category and laterality]
• Etiologic diagnosis: [Condition, onset date, key surgeries or interventions]
• Key impairments: [Weakness pattern, ataxia, dysphagia, aphasia, neglect, cognitive deficits, spasticity, pain, deconditioning, balance impairment] (List only those present)
• Activity limitations and safety risks: [Current limitations in mobility, ADLs, swallowing, communication, cognition with associated safety concerns]
• Rehab-relevant medical comorbidities: [Conditions impacting therapy tolerance or safety]
• Medical necessity for IRF level of care: [Therapy disciplines needed; anticipated ability to participate and benefit; physician supervision needs; 24-hour nursing needs; interdisciplinary coordination requirements]
• Anticipated length of stay: [Estimated LOS] Discharge plan: [Target destination with backup plan]
• Patient-centered goals: [Brief patient-stated goals] (Include 1–2 direct quotes when meaningful)

Chief Complaint

[Reason for IRF admission in one sentence] (Do not duplicate content from the Rehab Summary)

History of Present Illness

[Narrative timeline of acute event and hospital course including: onset date/time, initial presentation, ICU course, surgeries/procedures, key imaging findings. Current symptoms affecting rehab participation: pain, dyspnea, dizziness, fatigue, cognitive symptoms, bowel/bladder issues, sleep disruption. Therapy tolerance to date with limiting factors. Active complications and devices/lines/drains/orthoses with rehab implications.] (Use brief direct quotes only for patient goals or barriers. Attribute sources and note limitations when applicable.)

Functional Status

Premorbid Functional Baseline

• Mobility: [Household and community ambulation, wheelchair use, assistance level, device, distances] [Source]
• Transfers: [Bed, chair, toilet, car; assistance level; device/technique] [Source]
• ADLs: [Bathing, dressing, toileting, feeding; assistance levels; equipment] [Source]
• Cognition and communication: [Memory, attention, executive function, speech/language baseline] [Source]
• Swallowing and nutrition: [Baseline diet level, aspiration history, feeding method] [Source]
• Continence: [Bowel and bladder continence; management strategies] [Source]
• Baseline equipment: [Mobility aids, orthoses, ADL equipment] [Source]
• Living situation demands: [Home entry/stairs, bathroom access, bedroom level, caregiver availability] [Source]

(Use consistent assistance terminology: independent / supervision / contact guard / minimal assist / moderate assist / maximal assist / total assist)

Current Functional Status on Admission

• Mobility: [Bed mobility, gait, wheelchair propulsion; assistance level; distances; device; safety issues] [Source and date]
• Transfers: [Bed↔chair, toilet, shower; assistance level; technique; safety issues] [Source and date]
• ADLs: [Bathing, dressing, grooming, toileting; assistance level] [Source and date]
• Communication and cognition: [Barriers to participation; comprehension/expression; attention/memory/executive function] [Source and date]
• Swallowing and nutrition: [Current diet level; aspiration precautions; feeding method] [Source and date]
• Bowel and bladder: [Continence status; retention/incontinence strategy; catheter status] [Source and date]
• Skin integrity: [Wounds, pressure injuries with stage/location, device sites, risk level] [Source and date]
• Therapy evaluation status: [Completed / Pending] (If pending, document preliminary bedside snapshot and note that detailed scoring will follow therapy evaluations)

Past Medical and Surgical History

• [Condition] — [Active / Historical] — [Rehab relevance] (Prioritize cardiac, pulmonary, renal, endocrine, neuropsychiatric conditions, seizure history, anticoagulation indications, osteoporosis, fall history, prior functional impairments)
• Surgical history: [Relevant surgeries with dates; current hardware or precautions]

Source: [Patient / Family / Outside records / Prior EMR]

Allergies

• [Allergen] — [Reaction type and severity] — [True allergy / Intolerance]

(If none, state "No known drug allergies")

Medications

Home Medications

• [Medication, dose, route, frequency] — [Indication] [Source]

Acute Care Discharge Medications

• [Medication, dose, route, frequency] — [Indication]

IRF Admission Medication Orders and Reconciliation

• Continued: [Medications and rationale]
• Held/Stopped: [Medications and rationale]
• Restarted: [Medications and rationale]
• Changed: [Medications, new regimen, and rationale]

High-risk medication review: [Anticoagulants, insulin/sulfonylureas, opioids, benzodiazepines, antipsychotics, sedatives — indications, monitoring, risk mitigation]

Therapy-impacting effects: [Sedation, orthostasis, fall risk, delirium risk, analgesia timing]

Reconciliation status: [Complete / Partial] — [Sources used] — [Items pending and plan to complete]

Social History and Home Environment

• Living situation: [Residence type; with whom; caregiver availability and reliability]
• Home setup: [Entry steps; interior stairs; bathroom access; bedroom level; accessibility barriers]
• Community supports: [Home health, DME, transportation, community programs]
• Occupation and roles: [Employment, caregiving, volunteer roles, hobbies]
• Substance use: [Tobacco, alcohol, other] (Include only if relevant to rehab safety)
• Health literacy/communication: [Preferred language, literacy, interpreter needs]

Review of Systems

(Brief rehab-focused ROS; omit if adequately covered in HPI)

• Pain: [Location, quality, severity, triggers]
• Sleep: [Quality, latency, maintenance]
• Mood: [Anxiety/depression symptoms]
• Dizziness/orthostasis: [Symptoms and triggers]
• Dyspnea/exertional tolerance: [Baseline vs current]
• Bowel/bladder: [Constipation, diarrhea, retention, incontinence]
• Swallowing: [Coughing, choking, residue]
• Cognition: [Memory, attention, confusion]

Physical Examination

• General: [Appearance, alertness, distress, interaction quality]
• Vital signs: [BP, HR, RR, Temp, SpO2; orthostatic vitals if indicated; oxygen requirements]
• Cardiovascular: [Heart sounds, rate/rhythm; peripheral edema]
• Pulmonary: [Work of breathing; breath sounds; cough effectiveness]
• Abdomen: [Exam findings; tubes/devices]
• Skin: [Wounds, pressure injuries with stage/location, surgical sites, device sites]
• Neurologic and musculoskeletal:
  • Mental status: [Alertness, orientation, attention, command following]
  • Speech/language: [Fluency, comprehension, naming, dysarthria]
  • Cranial nerves: [Findings relevant to swallowing, neglect, vision]
  • Motor strength: [Key muscle groups with grades; laterality]
  • Sensation: [Light touch, proprioception, neglect testing]
  • Coordination: [Finger-nose, heel-shin, ataxia]
  • Tone/spasticity: [Location, severity, clonus]
  • Range of motion: [Limitations, contractures]
  • Pain exam: [Location, triggers, functional impact]
• Bedside mobility: [Supine↔sit, sitting balance, sit↔stand, standing balance, gait pattern] (If safely performed)
• Screening results: [Cognition, mood, or pain screens with tool name and score]

(Document only findings directly observed or verified; avoid auto-populated normal values)

Diagnostics

• Labs: [Pertinent values and trends affecting rehab tolerance/safety]
• Imaging: [Relevant conclusions and rehab implications]
• Microbiology/infection: [Active infections, organisms, isolation status]
• Consult recommendations: [Key recommendations affecting rehab plan]

Assessment and Plan

(Problem-oriented format ordered by severity and rehab impact)

Primary Rehab Diagnosis

Assessment: [Impairments, activity limitations, participation restrictions; expected functional improvement and timeframe]

• Therapy disciplines: [PT / OT / SLP / Neuropsych / Recreation Therapy / Orthotics] (State rationale for each)
• Interdisciplinary problem areas and goals: [Problem areas with responsible disciplines and measurable goals] (Preliminary pending therapy evaluations and team input)
• Precautions and monitoring: [Therapy-specific risks and mitigation]

Medical Comorbidities Affecting Rehab

Assessment: [Status of conditions limiting therapy participation]

• [Condition] — [Plan: medications, monitoring, consults, therapy implications]

Pain Management

Assessment: [Pain types and functional impact]

• [Pharmacologic regimen with timing relative to therapy]
• [Nonpharmacologic strategies]
• [Bowel prophylaxis if using opioids]
• [Monitoring for sedation/fall risk]

Bowel and Bladder

Assessment: [Continence status; retention/incontinence issues]

• [Bowel regimen and goals]
• [Bladder strategy: timed voids, catheter plan, PVR monitoring]

Skin and Wounds

Assessment: [Wound/pressure injury status and risk]

• [Positioning schedule and pressure offloading]
• [Wound care orders]

VTE Prophylaxis and Anticoagulation

Assessment: [Indication and bleeding risk]

• [Agent, dose, duration; mechanical prophylaxis]
• [Monitoring plan]

Swallowing and Nutrition

Assessment: [Diet level, aspiration risk, nutrition status]

• [Diet orders and aspiration precautions]
• [Tube feeding plan if applicable]
• [Nutrition consult and monitoring]

Cognition, Delirium, and Mood

Assessment: [Cognitive status, delirium risk, mood concerns]

• [Sleep hygiene and nonpharmacologic interventions]
• [Medication review for contributors]
• [Psychology/neuropsychology involvement]

Falls and Safety

Assessment: [Fall risk factors and safety concerns]

• [Supervision level; alarms if needed]
• [Orthostasis management; assistive device plan]

Disposition Planning

• Target discharge: [Destination with backup plan]
• Post-discharge services: [Home health / Outpatient therapy / SNF / Community programs]
• Equipment needs: [DME to arrange]
• Caregiver training: [Skills needed and who will be trained]
• Follow-up: [Appointments to schedule prior to discharge]