IRF Preadmission Screening Summary

IRF Preadmission Screening Summary

Patient: [Name]; [MRN]; [DOB]

Current Location: [Referring facility/unit]

Intended IRF: [Facility name]

Screening Date/Time: [Date and time]

Planned Admission Date/Time: [Date and time]

Screening Method: [in-person / chart review / phone / combination]

Screener: [Name]; [Credential]; [Role]; [Contact information]

Reviewing Rehabilitation Physician: [Name, credential]

Sources Reviewed:

• [Source document or interview] — [Author/discipline]; [Date]
• (Add additional items for each document reviewed: therapy evaluations, H&P, progress notes, nursing notes, labs/imaging, discharge summary draft, patient/caregiver interview.)

Limitations: [Unavailable key sources and alternate sources used] (Include only if source gaps exist.)

Screening Purpose

[Brief statement of screening purpose] (1–2 sentences stating this comprehensive preadmission screening summarizes medical and functional status to determine IRF appropriateness, including medical stability for intensive rehabilitation, multi-discipline therapy needs, expected intensity/tolerance, and reasonable expectation of measurable functional improvement.)

Medical Summary

Precipitating Event / Primary Rehabilitation Diagnosis: [Diagnosis or event leading to impairment with key dates and procedures]

Pertinent Comorbidities Affecting Rehabilitation: [Comorbidities that materially impact rehab intensity, safety, or monitoring] (Avoid exhaustive problem lists.)

Active Medical Management Needs During IRF Stay: [Respiratory support; hemodynamic monitoring; anticoagulation; pain regimen; dialysis schedule; wound care; nutrition/tube feeds; infection/isolation status; IV medications; glucose management; seizure precautions; other ongoing treatments] (List only applicable items with specifics.)

Recent Objective Data: [Relevant vital sign trends; pertinent labs/imaging] (Include only if available and relevant to stability assessment.)

Activity Restrictions: [Weight-bearing status; spine/hip precautions; sternal precautions; orthosis requirements; isolation status] (List restrictions that directly impact therapy.)

Medical Stability Assessment: [Explicit statement of readiness for intensive rehabilitation with supporting indicators: hemodynamic stability, respiratory adequacy, pain control, completion of acute workup, arousal/behavioral readiness] (If stability data are limited, document what is missing and what proxy sources were used. Do not infer stability.)

Current Precautions and Nursing Needs

• Precautions: [Fall; aspiration; seizure; orthopedic restrictions; isolation] (List all applicable.)
• Lines/Devices: [Central line/PIV; Foley; ostomy; feeding tube; tracheostomy; wound VAC; drains; cardiac devices]
• Skin Integrity: [Pressure injury staging/location; surgical wounds; skin tears; edema]
• Bowel/Bladder Program: [Continence status; program needs; management devices]
• Swallow/Airway Management: [Diet level; supervision needs; aspiration risk; suctioning needs]
• Behavioral Supervision: [1:1 sitter; elopement risk; agitation; cueing level; safety awareness]

(If items are unknown rather than absent, state "not assessed" or "not documented." Omit section only if nothing applies.)

Functional Status

Prior Level of Function

• Mobility: [Independent / Supervision / CGA / Min A / Mod A / Max A / Dependent]; [Device]; [Community vs household distances]
• Transfers: [Assistance level]; [Techniques/devices]
• ADLs: [Bathing]; [Dressing]; [Toileting] — [Assistance levels for each]
• IADLs: [Shopping; cooking; medication management; finances] (Include if relevant.)
• Cognition/Communication: [Baseline orientation; memory; attention; language/hearing/vision aids]
• Living Situation: [Alone / with others]; [Home setup including stairs, bathroom, bedroom location]
• Caregiver Availability: [Who; hours available; ability to assist]
• Baseline DME/Services: [Devices used; home health or community services]

Current Functional Status

Source and Date: [Therapy / Nursing / Physician source]; [Date] (If therapy evaluations unavailable, use best available proxy data and label the source.)

• Bed Mobility: [Assistance level]; [Limiting factors]
• Transfers: [Type]; [Assistance level]; [Device]; [Safety issues]
• Gait: [Distance]; [Device]; [Assistance level]; [Limiting factors]
• Wheelchair Mobility: [Distance; type; assistance level] (If applicable.)
• Stairs: [Steps; rail use; assistance level] (If applicable.)
• ADLs: [Feeding]; [Grooming]; [Upper/lower body dressing]; [Toileting]; [Bathing] — [Assistance levels and limiting factors]
• Swallowing: [Diet consistency]; [Aspiration risk]; [Supervision needs]
• Continence: [Bowel]; [Bladder]; [Management needs]
• Cognition/Communication: [Orientation]; [Attention]; [Memory]; [Safety awareness]; [Speech/language]
• Upper Extremity Function: [Strength/ROM/coordination]; [Dominant hand]; [Fine motor] (If relevant.)
• Standardized Scores: [Section GG items or other validated measures] (If available.)

Therapy Disciplines and Rationale

(Document need for active therapeutic intervention from multiple disciplines, with at least one being PT or OT. If only one discipline is indicated, state this and recommend alternate level of care.)

Physical Therapy

• Indication: [Mobility deficits: gait, transfers, balance, endurance, stairs, wheelchair skills]
• Skilled Interventions: [Anticipated interventions]
• Targeted Outcomes: [Functional goals]

Occupational Therapy

• Indication: [ADL/self-care, UE function, cognitive-perceptual deficits, adaptive equipment, home skills]
• Skilled Interventions: [Anticipated interventions]
• Targeted Outcomes: [Functional goals]

Speech-Language Pathology

(Include if indicated.)

• Indication: [Dysphagia; aphasia; dysarthria; cognitive-communication deficits]
• Skilled Interventions: [Anticipated interventions]
• Targeted Outcomes: [Functional goals]

Other Disciplines

(Include only if materially affecting admission rationale.)

• [Discipline] — [Rationale and goals]

Rehabilitation Intensity and Tolerance

Anticipated Intensity: [Total hours/week]; PT ~ [x] hrs/wk; OT ~ [x] hrs/wk; SLP ~ [x] hrs/wk; Other ~ [x] hrs/wk

Evidence Supporting Tolerance:

• [Observed endurance/participation during recent therapy with vitals response]
• [Cognitive/behavioral capacity for structured participation]
• [Pain control adequacy relative to activity]
• [Medical/therapy scheduling considerations]

Anticipated Barriers and Management: [Barriers: orthostasis, anemia, delirium, pain, cardiopulmonary limitations, isolation logistics] — [Mitigation strategies]

(If tolerance is uncertain, include reassessment plan within 24–48 hours and identify alternate setting if unable to participate.)

Risk for Clinical Complications

(Identify patient-specific risks requiring inpatient monitoring and interdisciplinary oversight.)

• [Risk]: [Patient-specific risk factors] — Mitigation: [Monitoring, nursing frequency, physician oversight, therapy modifications]
• (Add items as needed: falls, aspiration pneumonia, DVT/PE, wound breakdown, delirium, autonomic instability, cardiac/pulmonary exacerbation, infection, hypoglycemia, seizures.)

Expected Improvement and Timeframe

• Mobility: [Current level] → [Expected level]; [Timeframe]
• ADLs: [Current level] → [Expected level]; [Timeframe]
• Cognition/Communication: [Current level] → [Expected level]; [Timeframe]
• Swallowing: [Current level] → [Expected level]; [Timeframe]
• Estimated IRF Length of Stay: [x days] (If part of local practice.)

Rationale for Expected Improvement: [Prior independence; motivation; family support; early recovery signs; constraints and their impact on goals]

Discharge Planning

• Anticipated Disposition: [Home alone / home with family/caregiver / assisted living / SNF backup / undetermined]
• Home Environment: [Stairs and entry; bathroom/bedroom setup; accessibility barriers]
• Caregiver Availability/Training: [Who; hours; training needs]
• Post-Discharge Services: [Home health vs outpatient therapy; nursing; specialty follow-ups]
• DME Needs: [Anticipated equipment]
• Contingency Plan: [Steps to clarify if disposition undetermined]

IRF Appropriateness Determination

(Provide narrative justification addressing all CMS elements. Do not use checkboxes alone.)

• Multi-Discipline Therapy Need: [Disciplines required and brief rationale for each]
• Intensity Need: [Planned intensity] — Tolerance evidence: [Supporting facts]
• Medical Stability: [Key facts supporting readiness]
• IRF-Level Oversight Need: [Why physician supervision, rehabilitation nursing, and interdisciplinary coordination are required]
• Reasonable Expectation of Measurable Improvement: [Predicted gains and timeframe]

Conclusion: [Appropriate for IRF admission / Not appropriate for IRF—recommend (alternate setting) because (rationale)]

Patient and Family Engagement

[Patient's stated goals]; [Acceptance of IRF plan and intensity expectations]; [Barriers to participation and mitigation strategies] (Omit if engagement not feasible or documented elsewhere.)

Authentication

Screening Clinician Signature: [Name, credentials, signature]

Date/Time: [Date and time signed]

Rehabilitation Physician Review: The rehabilitation physician has reviewed this comprehensive preadmission screening and concurs that the screening supports the IRF appropriateness determination as documented above. This concurrence is recorded prior to execution of the IRF admission order.

Physician Signature: [Name, credentials, signature]

Date/Time: [Date and time signed]

48-Hour Update Addendum

(Include if screening completed more than 48 hours before planned admission.)

Update Date/Time: [Date and time]

Method: [phone / in-person / combination]; Updated by: [Name, credential, role]

• Medical Status Changes: [New issues; resolved issues; treatment changes] (Or state "no material change.")
• Functional Status Changes: [Improved/worsened domains with specifics] (Or state "no material change.")
• Ability to Participate: [Updated tolerance evidence or concerns]
• Overall Impact on IRF Appropriateness: [No material change—still appropriate / Now not appropriate because (rationale)]

Rehabilitation Physician Review of Update: [Statement of concurrence with updated information and appropriateness determination]

Physician Signature: [Name, credentials, signature]   Date/Time: [Date and time signed]