Contains general demographic and family contact information, general consent forms, insurance data, social work, and psychosocial intake assessments.

Contains reason for admission, injury history, pertinent medical history, results of the physical examination and the original problem list. In the rehabilitation setting, H&P will typically include the timeline and course of treatment prior to admission to the rehabilitation setting. This section often serves as the most complete narrative of the patient’s condition.

Contains results from diagnostic studies. The organization can be variable but typically includes cardiac rhythm testing, echocardiogram, electrocardiogram (EKG), electromyography (EMG), swallow studies, sleep studies, X-ray, electroencephalogram (EEG), and imaging such as computed tomography (CT) and magnetic resonance imaging (MRI).

Treatment orders and physician order sets

Contains pharmacy orders and medication history

Results of chemistry, microbiology, hematology, urinalysis/stool testing, and blood alcohol (ETOH) and illicit drug testing

Contains consultation notes from specialties outside of the primary medical service line. Psychology and psychiatry consultation reports are often found in this section.

Contains evaluations from audiology, physical therapy (PT), occupational therapy (OT), speech and language pathology (SLP), social work, and pressure sore flow sheets. OT/PT/SLP may have independent sections in the rehabilitation setting.

Daily documentation of patient progress with multiple providers documenting their encounter with the patient

Contains individual treatment plans, critical care plans, and/or behavioral management plans

Contains powers of attorney, advance directives, and legal guardianship

General guidelines

Accurate and timely documentation are critical to safe and effective patient care. The clinician must be aware of hospital or facility policies on documentation requirements and timelines. Although there is institutional and practice variation, inpatient encounters are typically documented in the medical record on the day the encounter takes place. If a delay in providing a complete report is necessary, interim documentation needs to be done to communicate contact with the patient and any urgent information (i.e., “hold” note). Outpatient encounters are generally required to be completed within one week, although as EMR become more commonplace, quicker turnaround is becoming the new standard.

Interview reports

The interview report is used to provide a clear and concise initial impression and framework for developing an actionable treatment plan. The documentation should focus on pertinent information that guides patient care. Clinicians should work to avoid redundancy with other easily accessible parts of the medical record (e.g., medical history). Emphasis should focus on the factors assessed by psychology such as cognition, mood, behavior, social/environmental variables, impairments, and retained abilities or the patient’s assets. Recommendations should make up the most significant portion of the interview report and should provide guidance to the team, patient, and family.

Progress notes provide encounter-specific information and documentation of treatment and intervention progress. The purpose is to document the clinician’s intervention and that you are following acceptable standards of care and clear rationale and results of interventions. In multidisciplinary settings, progress notes allow the team to stay abreast of each provider’s observations and interventions. Progress notes are significantly different than psychotherapy process notes, which might include hypotheses, treatment, or diagnostic considerations that are later discarded. Thus, information provided in the progress note should be brief and provide salient information to document and communicate important information to other clinicians for the explicit purpose of improving recovery. They are not intended to provide a detailed narrative. If the progress note is serving as the supporting documentation for billing purposes, which is often the case, the note must include required elements (e.g., date/time of encounter, procedure used, time devoted (if a time-based CPT), and diagnosis).