IRF Rehabilitation Physician Progress Note

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifier]

Provider: [Physician name and credentials]

IRF Day/LOS: [IRF day number and total length of stay]

Primary Rehab Diagnosis: [Primary rehabilitation diagnosis/impairment group]

Discharge Target: [Date and destination if known, or "TBD"]

Interval History

[Reason for today's supervision visit and interval changes since last note] (In 1–2 short paragraphs, begin with the explicit reason for today's visit. Include patient-reported changes in pain, sleep, appetite, dizziness, mood/cognition as relevant; therapy participation and tolerance including any refusals or missed sessions with stated reasons using direct quotes; and significant interval events such as falls, transfers off-unit, new consults, or procedures. If a key item was not assessed, write "Not assessed today." Do not include a full review of systems.)

Objective

• Vitals: [Relevant vitals and trends affecting therapy participation]
• Exam: [Focused exam tied to active problems—general appearance, neuro/functional neuro, MSK, skin, cardiopulm as indicated] (Document only systems examined today. State "Not assessed today" for commonly relevant elements not examined.)
• Functional Status: [Mobility, ADLs, swallow/communication, cognition—include assist levels and quality for each domain assessed] (Attribute each domain to source: "Observed today," "Per PT/OT/SLP (date)," or "Per nursing." If today's data unavailable, use most recent therapy documentation with date clearly labeled.)
• Data: [Pertinent labs, imaging, or medication changes affecting rehab participation]

Assessment

[Integrated assessment of medical and functional status] (Write 3–6 sentences linking current medical stability to ability to participate in intensive inpatient rehabilitation. Identify primary drivers of progress and primary barriers. State whether the course is on track for expected discharge. When barriers arise or discharge plan changes, briefly justify ongoing need for IRF-level care.)

Plan

1. [Problem 1]: [Problem statement with rehab implications and current management] (Order problems by impact on rehabilitation participation.)
2. [Problem 2]: [Problem statement with rehab implications and current management]
3. [Additional problems as applicable]

• Therapy coordination: [Disciplines involved; changes to frequency/intensity/precautions; mitigation plan for missed therapy or reduced tolerance]
• Goal progress: [1–2 key functional goals with measurable elements and next barrier-limited step]
• Discharge planning: [Anticipated date/destination; barriers such as stairs, caregiver, equipment, medical; DME needs; services on discharge; caregiver training status] (If unknown early in stay, document what is being assessed to determine it.)
• Orders today: [Medication changes, labs, consults, procedures with indication]
• Care coordination: [Team communications, decisions made, patient/family counseling]

(Omit bullets that do not apply. Use "Not assessed today" where appropriate rather than implying normal findings. Do not copy forward functional text without updating dates and sources.)