Article

Physical therapists require a comprehensive assessment of
a patient's functioning status to address multiple problems in patients with severe conditions. The International Classification of Functioning, Disability
and Health (ICF) is the universally accepted conceptual model for the description
of functioning. Documentation tools have been developed based on ICF Core Sets to
be used in multidisciplinary rehabilitation management and specifically by
physical therapists. The purposes of this case report are: (1) to apply ICF-based
documentation tools to the care of a patient with spinal cord injury and (2) to
illustrate the use of ICF-based documentation tools during multidisciplinary
patient management. CASE DESCRIPTION: The patient was a 22-year-old man with
tetraplegia (C2 level) who was 5 months postinjury. The report describes the
integration of the ICF-based documentation tools into the patient's examination,
evaluation, prognosis, diagnosis, and intervention while he participated in a
multidisciplinary rehabilitation program for 2 months. OUTCOMES: The patient's
comprehensive functioning status at the beginning of the program, the
rehabilitation goals, the intervention plan, and his improvements in functioning
following rehabilitation and the according goal achievement were illustrated with
physical therapy-specific and multidisciplinary ICF-based documentation tools.
DISCUSSION: This case report illustrates how the ICF-based documentation template
for physical therapists summarizes all relevant information to aid the physical
therapist's patient management and how ICF-based documentation tools for
multidisciplinary care complement one another and thus can be used to enhance
multidisciplinary patient management. In addition,
the ICF assists in clarifying
clinician roles as part of a multidisciplinary team. The case report demonstrates
that the ICF can be a viable framework both for physical therapy and
multidisciplinary management and for clinical documentation.

Langue : ANGLAIS