Information Gathering and Documentation

Abstract

The medical record is the central source for information in the inpatient and acute medical setting. While the organization of the medical record may differ slightly depending on setting, medical documentation is universal in medical care and provides the essential vehicle for communicating and documenting information across multiple disciplines. In the acute and subacute medical setting, the medical record is a dynamic and “living” document with contributions from those providing direct clinical care and treatment, documentation of results, as well as information to determine future intervention and discharge. The following chapter provides basic information on record organization, data-gathering strategies, and typical types of clinical documentation used in medical rehabilitation.