Documentation for Measuring Stroke Rehabilitation Outcomes

Abstract

Stroke is the third commonest cause of hospital admission in Australia. Approximately 71% of patients with an acute stroke are likely to be admitted to public and private hospitals. With no advanced clinical information system in place in Australia, it is difficult to determine who is likely to benefit, what type of inpatient care is efficient and effective in providing maximum potential to the stroke patients. This paper highlights some of the problems encountered with the current medical records, in conducting a prospective, multi-institutional, population based stroke rehabilitation outcome study in Brisbane. The paper also discusses how these deficiencies affect health professionals such as occupational therapists, and how one can work with the medical record administrators of today as key resource people in health information management. To illustrate this, a pro forma rectifying some of the current deficiencies in the medical records is provided as a guide. (AMRJ, 1991, 21(3), 88–95).