Home > RNJ > 2007 > May/June > Current Issues: How Interdisciplinary Documentation Improves the Bottom Line

Current Issues: How Interdisciplinary Documentation Improves the Bottom Line
Carol Harper, COTA

As rehabilitation facilities continue to dissect their quarterly reports and modify internal practices to improve organizational outcomes, they continue to struggle as they implement interdisciplinary documentation that can validate the practice. The implementation of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) in January 2002 forced the rehabilitation industry to recognize the importance of documentation to support the burden of care 24 hours a day, 7 days a week, ensuring accurate reimbursement and positive outcomes. Too often, facilities that struggle with outcomes management continue to work as discipline-specific teams within the rehabilitation unit. Developing practices and guidelines for everything from preadmission to discharge can help a facility achieve better outcomes and overall operational efficiency. Creating interdisciplinary communication and documentation is crucial to developing an interdisciplinary practice. With collaboration of all members of the rehabilitation team and comprehensive documentation, the needs of the patient can be addressed, thus capturing the burden of care to attain the appropriate reimbursement and ensure the most appropriate discharge destination.

The types of patients being admitted to a rehabilitation unit are a factor when outcomes for a positive change are reviewed. With this in mind, a comprehensive preadmission screening process is essential to ensuring that appropriate patients are being identified. The following factors should be considered:

  • What is the predicted admission impairment group code (IGC)?
  • What are the patient’s deficits?
  • What was the patient’s prior level of function?
  • What is the patient’s current level of function?
  • Is the patient medically stable?
  • Will the patient be able to return to a community setting?
  • Does the patient have adequate family support or community support available if necessary?
  • Does the patient need an intensive inpatient rehabilitation program?
  • Can the patient tolerate an intensive level of rehabilitation?

A negative outcome may be inevitable if any of these areas are not considered prior to admission. Developing preadmission guidelines that assist in the admission of appropriate rehabilitation patients can be instrumental to achieving successful outcomes. Evaluating outcomes (e.g., discharge destination, facility reimbursement, Functional Independence Measure (FIM™) change, patient estimated length of stay, and overall length-of-stay efficiency) will assist in modifying and enhancing current practices.

After the patient is admitted to the rehabilitation unit, the physician is responsible for accurately identifying and documenting all medical information necessary to assign the admission IGC, etiology, comorbid conditions, and complications throughout the rehabilitation stay. The admission history and physical should clearly support the reason for admission to rehabilitation (the IGC), the condition that led to the impairment (etiology), and all other current conditions that affect the rehabilitation stay (comorbid conditions). When these are left to an interpretation by someone other than the physician, the wrong IGC can easily be chosen. When a patient’s medical conditions are not identified accurately on the IRF-Patient Assessment Instrument (IRF-PAI), the result often is inconsistent outcomes that cannot be compared with national benchmark data. For example, when a patient is admitted after undergoing a laminectomy with documentation supporting lower extremity weakness, and the physician also documents neurogenic bowel and bladder in the physical examination, the IGC would be expected to be Non-Traumatic Spinal Cord Dysfunction 04.130. However, if documentation is unclear, the interpretation may be weakness without neurologic deficits. In this case, the IGC may be coded as Other Orthopaedic 08.9 and may result in very different outcomes (and ultimately reimbursement). In addition, only medical conditions identified and documented by a physician can be coded by a medical coder for the IRF-PAI. Thus, without clear and specific documentation by the physician, conditions may be inadvertently excluded.

Although the FIM™ instrument was never intended to be a discipline-specific tool, it has often been used in such a manner by the rehabilitation industry. Typically, nursing was responsible for bowel and bladder management and toileting; occupational therapy was responsible for self-care components, tub and shower transfer, and toilet transfer (as well as communication and cognition if speech–language pathology was not involved); physical therapy was responsible for locomotion, bed/chair/wheelchair transfer, and stairs; and speech–language pathology, if involved, was responsible for the cognitive items. The IRF PPS has made it necessary for all rehabilitation units to use the FIM™ instrument as an interdisciplinary tool. All clinicians regardless of discipline must have the knowledge and ability to accurately document each interaction with a patient to capture the greatest burden of care (lowest FIM™ rating) during the 3-day admission assessment time frame regardless of where and when the activity occurs (Centers for Medicare & Medicaid Services, 2004; 2006; Uniform Data System for Medical Rehabilitation, 2001). Documentation includes not only an FIM rating but support for how that rating was determined. As members of rehabilitation facilities can attest, this requirement has put an added challenge on facilities to ensure that the staff understands the following:

  • Each FIM™ item definition regardless of discipline
  • The seven-level FIM™ rating scale
  • The appropriate use of code 0
  • Compliance with documenting every burden of care

FIM™ rating patterns can easily be examined via the facility’s case-mix group adjusted quarterly report by analyzing the facility admission FIM™ rating by impairment. Large differences between the facility’s pattern and the adjusted national average may indicate a FIM™ rating inconsistency or noncompliance with rating guidelines. In addition, an audit of the admission ratings placed on the IRF-PAI may indicate an overuse of code 0 that warrants attention and perhaps staff re-education.

Facilities have often discovered that specific disciplines are not documenting the burden of care for an item either because the facility or discipline continues with a discipline-specific mentality (or assessment form) or because the therapy staff has not evaluated the patient in a specific area. Reiterating the interdisciplinary practice is essential in capturing the true burden of care. All staff members must understand that the therapy staff does not need to complete a formal initial evaluation for a burden of care to occur with another discipline. Such education may assist in capturing the true burden of care during the admission process and throughout the rehabilitation stay. As indicated in the IRF-PAI Training Manual (CMS, 2004, section III-1), any trained clinician, regardless of discipline, can use the FIM™ instrument to measure disability; such measurements should be documented clearly in the medical record. The most common problem observed in rehabilitation facilities is that the nursing staff does not capture their round-the-clock burden of care 24 hours a day via documentation. For example, the nursing staff does not document the burden of care for bathing (even though they assist the patient in the morning) because the occupational therapy staff has not performed the initial evaluation or because the nursing staff does not understand the importance of this information. Documentation must support the nursing staff’s burden of care for any FIM™ item they assist with; at the same time, however, the nursing staff must continue with the medical and surgical documentation as usual (with the combination representing rehabilitation nursing). IRFs across the industry have found themselves in a quandary in this area. Many have developed interdisciplinary flow sheets to alleviate some of the burden for nursing staff when documenting required functional status and the burden of care for the patient and to encourage an interdisciplinary practice.

Throughout the rehabilitation stay, daily communication within the interdisciplinary team, along with a more formal team conference meeting (usually at least once a week), should concentrate on established goals, patient progress, and any barriers, functional or medical, that may prevent the patient from achieving those goals before discharge. After obstacles have been identified, they should be addressed immediately, and the plan of care and rehabilitation goals should be modified if necessary.

As indicated earlier, evaluating the facility’s outcomes will assist in the admission process, as will evaluating the discharge data. A review of the patient’s FIM™ ratings on discharge, the FIM™ change from admission to discharge, the actual length of stay, the length-of-stay efficiency, and the discharge destination in comparison to the nation may identify areas that warrant attention. For example, if the data for the spinal cord dysfunction impairment group supports an average onset date of 15 days, but the onset for the nation is 30 days, further examination of the data is warranted. Bowel and bladder FIM™ ratings on admission, transfer status, and a determination of whether stairs were assessed all could indicate whether the patient has a true spinal cord injury or whether the wrong impairment group code was chosen on admission.

The Medicare Benefit Policy Manual (CMS, 2006) has specific requirements that an IRF must follow to justify intensive inpatient rehabilitative services. Participating facilities must be able to demonstrate the following (not an all-inclusive list):

  • The need for 24-hour availability of a registered nurse with specialized training or experience in rehabilitation
  • A multidisciplinary team approach to program delivery that includes a physician, a rehabilitation nurse, a social worker and/or psychologist, and the therapists involved in the patient’s care
  • A coordinated program of care supported by documented, periodic team conferences

Best practice is to represent the team’s ability to assess a patient’s progress or barriers to discharge, consider possible resolutions to such problems, and reassess established validity of goals when necessary. Successful IRFs have developed a comprehensive rehabilitation plan of care as a way to communicate between all staff members (including all nursing shifts). The entire team is responsible for using the comprehensive rehabilitation plan of care to follow through with established treatments and the patient’s plan of care and to formulate recommendations based on the patient’s medical and functional needs as the patient progresses throughout the rehabilitation stay. After barriers are identified, interdisciplinary team meetings demonstrate the coordinated program of care by adjusting the patient’s short-term goals, long-term goals, and plan of care to enable a safe discharge for the patient at the most independent level. Many facilities have implemented daily morning rounds, which immediately communicate, both verbally and via documentation in the medical record, issues that the team must address.

In review, developing a strong interdisciplinary practice within your IRF and providing documentation that supports it will help you attain reliable, valid data and will enable your facility to manage and improve outcomes. Establishing this practice and representing it in your documentation allows you to properly capture a patient’s functional improvement as measured by the patient’s FIM™ ratings. Data that represent a true picture of each patient can be used to develop new practices that enhance the positive outcomes the entire staff is working so hard to achieve.

About the Author

Carol Harper, COTA, is a supervisor at UDSMR Education and Training, Amherst, NY. Address correspondence to her at 270 Northpointe Parkway, Suite 300, Amherst, NY 14228, or charper@udsmr.org.


Centers for Medicare & Medicaid Services. (2004, April 1). IRF-PAI training manual. Buffalo, NY: Author.

Centers for Medicare & Medicaid Services. (2006, February 10). Medicare benefit policy manual, Chapter 1, “Inpatient hospital services covered under Part A,” Rev. 45. Buffalo, NY: Author.

Uniform Data System for Medical Rehabilitation. (2001). The UDS-PRO® system (including the FIM instrument) clinical guide, version 1.0. Buffalo, NY: Author.