A rehabilitation evaluation system which complements the problem-oriented medical record.

Area of Science:

• Rehabilitation Medicine
• Medical Informatics
• Patient Assessment

Background:

• Traditional medical history and physical examination formats are disease-centered, proving insufficient for comprehensive rehabilitation patient evaluation.
• The Problem-Oriented Medical Record, while valuable, presents challenges in complexity and diversity for rehabilitation settings.
• A need exists for a specialized tool to effectively document and track functional progress in rehabilitation.

Purpose of the Study:

• To introduce and detail the Rehabilitation Evaluation System (RES), a novel tool for documenting functional rehabilitation management.
• To demonstrate the RES's utility in tracking patient progress during both inpatient and outpatient phases.
• To highlight the RES's advantages in clinical practice, education, and research within rehabilitation.

Main Methods:

• Development of the Rehabilitation Evaluation System (RES), comprising 18 key rehabilitation areas.
• Each area is assessed using an objective, four-point rating scale.
• The RES was applied to 46 rehabilitation inpatients across various conditions, including stroke, spinal cord injury, and orthopedic trauma.

Main Results:

• The RES was utilized effectively across a diverse inpatient rehabilitation cohort.
• The system proved invaluable for formulating patient goals and continuously monitoring the rehabilitation process.
• The mechanics of the RES were detailed, including a case example of hemiplegia.

Conclusions:

• The Rehabilitation Evaluation System (RES) provides a structured, disability-oriented framework for rehabilitation assessment.
• The RES facilitates goal setting, progress evaluation, and comprehensive documentation in rehabilitation care.
• The system offers practical benefits for patient care, medical education, record-keeping, and research, complementing existing medical records.