IRF Individualized Overall Plan of Care

Patient Name: [Patient name] MRN: [Medical record number] DOB: [Date of birth] Admission Date: [IRF admission date]

IRF Day: [IRF day number] Plan Date/Time: [Plan creation date/time] Unit/Room: [Unit/Room] Rehabilitation Physician: [Physician name, credentials]

Admission Source: [acute hospital / SNF / community] Primary Reason for IRF Admission: [Primary rehabilitation diagnosis]

[Purpose statement establishing this as the individualized overall plan of care] (1–2 sentences. State whether this is an initial plan or revision; if revision, briefly state reason and reference date of prior plan.)

Rehabilitation Admission Summary

[Narrative summary of rehabilitation admission] (3–6 sentences covering: primary rehabilitation diagnosis/impairment and etiology with event date; key comorbidities affecting participation, safety, or discharge; pre-event functional baseline across mobility/ADLs/cognition—state "unknown" if unavailable with plan to obtain; current functional limitations by domain including mobility/transfers, self-care, cognition/communication, swallowing, bowel/bladder, skin. Conclude with brief justification for why IRF-level care with intensive interdisciplinary therapy and 24-hour rehabilitation nursing/physician oversight is required.)

Prognosis and Expected Improvement

• Medical stability: [Expected medical course during IRF stay and therapy tolerance criteria]
• Expected functional improvement: [Time-bounded, measurable improvement statement linked to impairments and planned interventions] (Be specific and patient-centered; avoid generic statements like "good rehab potential.")
• Key barriers/risks: [Barriers to progress with mitigation strategies] (e.g., pain, fatigue, delirium risk, caregiver limitations)

Rehabilitation Goals

Patient-stated goals:

• [Patient goal in patient's words] (Cite source if obtained from surrogate.)
• [Additional patient goal] (Include 1–3 goals as available.)

Interdisciplinary Functional Goals:

Domain	Baseline	Target	Assistance/Device	Timeframe
[Mobility – Bed mobility]	[Current performance]	[Target performance]	[Assist level/devices]	[Days/weeks]
[Transfers]	[Current performance]	[Target performance]	[Assist level/devices]	[Days/weeks]
[Gait/Wheelchair mobility]	[Current distance/surface]	[Target distance/surface]	[Assist level/devices]	[Days/weeks]
[Self-care]	[Current performance]	[Target performance]	[Assist level/devices]	[Days/weeks]
[Cognition/Communication]	[Current deficits]	[Functional target]	[Strategies/devices]	[Days/weeks]
[Swallowing/Nutrition]	[Current diet/status]	[Target diet/safety]	[Strategies]	[Days/weeks]
[Safety/Caregiver training]	[Current status]	[Target competence]	[Training topics]	[Days/weeks]

(Include 3–8 prioritized functional outcomes. Remove non-applicable rows. Mark goals as provisional if therapy evaluations are pending.)

Therapy Program

Discipline	Minutes/Day	Days/Week	Total Days	Primary Focus	Tolerance Constraints
PT	[Minutes/day]	[Days/week]	[Total days]	[Primary PT focus]	[Hold parameters]
OT	[Minutes/day]	[Days/week]	[Total days]	[Primary OT focus]	[Hold parameters]
SLP	[Minutes/day / Not indicated]	[Days/week]	[Total days]	[Primary SLP focus]	[Hold parameters]
Prosthetics/Orthotics	[Minutes/day / Episodic consult / Not indicated]	[Days/week]	[Total days]	[Device focus]	[Coordination notes]

[Therapy intensity rationale] (2–4 sentences linking impairments and functional status to the planned distribution of minutes by discipline. Note anticipated variations such as dialysis or infusion days.)

Mode of therapy: [Individual / Group / Co-treatment] (If group or co-treatment planned, specify disciplines and clinical rationale.)

Rehabilitation Nursing Priorities

• Fall risk and mobility: [Risk level, assist level, alarms, rounding frequency]
• Skin integrity: [Turning schedule, support surfaces, wound care]
• Bowel program: [Schedule, medications, monitoring]
• Bladder program: [Voiding schedule/catheter plan, PVR checks]
• Pain management: [Medication timing relative to therapy, nonpharmacologic strategies]
• Swallow precautions: [Diet level, positioning, supervision] (Only include if applicable.)
• Lines/tubes/drains: [Device list, care, mobility routing] (Only include if applicable.)
• Delirium prevention: [Orientation cues, sensory aids, sleep hygiene] (Only include if applicable.)

(If any nursing program component is pending, document interim plan and expected finalization date.)

Medical Management Plan

(List 5–12 active medical problems impacting rehab participation, safety, or discharge. Prioritize items affecting precautions, tolerance, or therapy timing.)

• [Problem 1]: [Assessment and management plan with monitoring parameters]
• [Problem 2]: [Management and monitoring notes]
• [Problem 3]: [Management and monitoring notes]
• [Problem 4]: [Management and monitoring notes]
• [Problem 5]: [Management and monitoring notes]

(Include high-risk medication considerations and anticipated consultations as relevant.)

Precautions and Safety Parameters

Mobility/Orthopedic:

• [Weight-bearing status with source of restriction]
• [ROM restrictions or spine/hip precautions with duration]
• [Orthoses/bracing requirements] (Only include if applicable.)

Neurologic:

• [Seizure precautions and rescue plan] (Only include if applicable.)
• [Supervision level for mobility/ADLs]

Swallowing/Respiratory:

• [Diet level and aspiration precautions]
• [Oxygen/respiratory parameters and therapy hold criteria] (Only include if applicable.)

Wounds/Lines/Isolation:

• [Wound care and offloading] (Only include if applicable.)
• [Lines/tubes/drains with mobility guidance] (Only include if applicable.)
• [Isolation status] (Only include if applicable.)

(If no precautions beyond standard protocols, state: "No additional precautions beyond standard IRF protocols.")

Discharge Plan

• Estimated LOS: [Numeric range in days] ([Key drivers for LOS])
• Anticipated Discharge Destination: [Primary goal] (Backup: [Alternative if applicable])
• Discharge Needs:
  • Services: [Home health / Outpatient therapy / Other]
  • DME: [Equipment needs]
  • Caregiver training: [Required skills, learner availability]
  • Home setup: [Barriers and mitigation plan]
• Decision status: [If undecided: leading options, information needed, responsible party, target decision date]
• Early planning actions: [Referrals, home assessment, equipment trials, family meeting date]

Interdisciplinary Contributors

• PT: [Name/role / Input pending by date]
• OT: [Name/role / Input pending by date]
• SLP: [Name/role / Not indicated]
• Rehabilitation Nursing: [Name/role]
• Case Management/Social Work: [Name/role]
• Other: [Additional contributors / Not involved] (e.g., Psychology, Dietitian, Prosthetist)

Attestation

I attest that this individualized overall plan of care was developed with interdisciplinary input and reflects the patient's medical, functional, and discharge needs for this IRF admission.

Rehabilitation Physician Signature: ________________________________ Date/Time: __________________

(If required information is unavailable, insert placeholder stating what is missing and when it will be obtained. Clinical inference for rehabilitation potential is acceptable when supported by documented rationale. Do not infer patient goals/preferences or caregiver availability without citing source. This is the initial overall plan of care; updates occur via addendum or weekly team conference when significant changes arise.)