IRF Documentation

doctor using medical program

Netsmart acquired UDSMR in March 2022. Prior to this acquisition, Netsmart and UDSMR had been partnering to build the RehabConnect™ System within the Netsmart CareFabric® solution. Since the acquisition, our teams have worked together to merge both products into one, and we are excited to announce RehabConnect™ 2.0, the next generation of the UDS‑PRO Doc™ System!

The RehabConnect™ System helps clinicians and rehab coders generate accurate ratings by combining the two requirements of documenting care and rating items on the IRF-PAI into one task. Designed to interface with other hospital information systems in order to improve efficiencies and eliminate errors, our IRF system is capable of warehousing as much clinical data as your facility desires. Its design also allows it to interface with electronic health record (EHR) and electronic medical record (EMR) systems that your facility may already be using.

The RehabConnect™ System is designed to meet all of CMS's very specific requirements for IRF documentation, many of which are not included in the most common electronic documentation systems. Our advanced tools also help clinicians keep up with proper documentation to make sure everything meets the requirements for Medicare's IRF-reimbursement. The documentation templates include FIM® logic that helps clinicians determine accurate ratings throughout each patient’s stay, and the clinical documents include the quality indicator items required on the IRF-PAI. The design of the system allows users to efficiently review all required data and to save the information directly to the IRF-PAI, and its administrator tools facilitate oversight of required tasks and time frames related to compliance.

RehabConnect™ Advantage

IRF System framework

Cloud or facility-hosted server options for working in Citrix and VMware environments

Instant exchange of IRF-PAI data between the RehabConnect™ System and the UDS-PROi® software

A wide choice of installation options, including:

  • Simple, noninterfaced, out-of-the-box setup
  • Comprehensive, seamless HL7® interfacing with EMR and billing systems exchanges
  • Automated PDF clinical document exchange to medical records for concurrent information and storage

A billing module that incorporates the hospital’s chargemaster into appropriate therapy documents for easy integration of therapy codes and units of service back to the billing system in real time

Simplified sign-on and enhanced security with optional LDAP/SSO solutions

Semiannual updates that maintain CMS’s latest IRF PPS standards and requirements at all times

Clinician tools

A collection of ready-to-use physician, nursing, and therapy templates

  • Facility-defined mandatory fields and/or discipline-specific expectations within documents
  • Built-in section GG coding assistance, including detailed drop-down selections
  • Copy-forward functionality with clinician access set by administrative users

Integrated therapy tracker that compiles minutes and modes, transfers information to the IRF-PAI and provides weekly summaries of your patients’ daily compliance with CMS’s therapy-intensity rule

SmartQI™ logic that tracks the patient’s initial assessment and all other relevant QI documentation and recommends the optimal admission and discharge codes

Electronic “sticky note” feature that facilitates real-time team communication about the patient

Quickly assembled plan of care (IPOC) and weekly team conference, compiled from relevant clinical assessments and progress notes

Administrative oversight

Individual end-user to-do lists with automatic reminders and warning flags for missing or pending CMS requirements or facility-defined criteria

Report views that trend patient data for numerous variables, including therapy minutes, section GG codes, vitals, education, and pain

Real-time document status reports and other oversight tools that provide elevated views for managing entire documentation processes

Collation of all pertinent information into one location for easy review before data is committed to the IRF-PAI

RehabConnect™ Benefits

The RehabConnect™ System’s many clinical templates are built according to the documentation guidelines and logic in The IRF-PAI Manual, as well as the requirements in the Medicare Benefit Policy Manual. This integrated logic improves compliance and makes cases more likely to stand up to a review or an audit.

The clinician-friendly software supports interdisciplinary documentation, thus making it easier for your entire rehab team—nurses, therapists, and physicians—to work together.

The tasks of documenting patient care and supporting IRF-PAI coding are combined into one, thereby increasing efficiency and improving accuracy.

The QI Manager compiles all relevant IRF-PAI documentation throughout the system into one module whose built-in proprietary logic eases the burden of supporting IRF-PAI codes.

The software automatically extracts therapy treatment times and modes from the various therapy documentation and eliminates the tedious burden of calculating total therapy values and recording them on the IRF‑PAI.

The software’s optional HL7® interfacing optimizes efficiency and reduces data-entry duplication and errors.

Intuitive flags, views, and reports throughout the system increase compliance with regulatory requirements and provide more efficient workflow and real-time administrative oversight.

The software allows facilities to define and manage their own required fields, discipline-specific expectations within documents, task lists, user privileges, and more!

RehabConnect™ Technical Specifications

Smart Client Technology: The system uses Microsoft’s new “smart client” technology. Microsoft® smart client applications combine the ease of use of Microsoft® Office desktop applications, the performance of client-server applications, and the reach of the Internet.

The result is unparalleled ease of use and performance within a secure, multi-user database environment. Utilizing this technology, the RehabConnect™ System can be accessed through any Internet-enabled computer—and, at the same time, the system can interface with any hardware device (e.g., scanners) on the user’s computer or network.

Powerful Interfacing: The system uses an HL7® interface to communicate with other hospital information systems already in use, providing the power to pull all the patient’s information into the RehabConnect™ System and to have all the critical information on display in one place. The interface improves efficiencies between hospital systems, eliminates errors due to “double data entry,” and ensures accurate information across all systems.

RehabConnect™ Clinical Documents

Facesheet: This module combines patient data from your facility’s hospital information system with the IRF‑PAI.

Clinical Summary: This module provides a snapshot of pertinent patient information collected from multiple interdisciplinary documents.

Plan of Care: The POC module displays the physician’s individualized overall plan of care and automatically pulls interventions, problems, focus areas, and goals together from admission assessments for easy access and tracking.

Clinical Documents: These comprehensive and customizable documentation templates support medical necessity, generate accurate section GG codes, provide documentation that supports all the quality indicator data elements, and demonstrate interdisciplinary team communication.

QI Manager: This module, which is built according to CMS’s technical specifications, consolidates all IRF-specific regulatory documentation from various sources into one central location, with direct integration with the UDS-PROi® software and the IRF-PAI.

CareTrend PRO™ Module: This module includes therapy treatment time logs, section GG coding trends, pain ratings and interventions, and interdisciplinary education for user-defined time frames.

Patient Summary: This customizable interdisciplinary electronic sticky note facilitates real-time communication among team members about important patient care information.

Task List: This set of system flags helps facilities manage regulatory and facility-defined time frames related to clinical documentation requirements.

Required Fields: Administrators can define facility-specific expectations for areas in each clinical document that must be addressed before the document is completed to ensure compliance.

Reports: Multiple baseline reports, including reports on therapy treatment time, clinical document completion status, and interim functional QI documentation, help facilities improve their regulatory compliance.

Health Record Integration Tool: This optional module allows your facility to automate the transfer of clinical documents from the RehabConnect™ System to your facility’s full EMR.

User Setup: This module allows administrators to set up RehabConnect™ user accounts with a customizable and unique set of permissions for each user.

Audit Log: This logging system tracks changes made to the entire documentation system, including user access, data changes, and module access.

Online Help: This series of documents provides complete and comprehensive online documentation for the entire software system. The documentation is specific to each module and screen, providing users with the quick and easy access to the specific help they need.