Content identification of the interdisciplinary assessment of cerebral palsy using the International Classification

P M O Andrade1, Fernanda Oliveira Ferreira, Ana Paula Mendonça

  • 1Federal University of Minas Gerais, Programa de Pós Graduação em Neurociências, Belo Horizonte, Brazil. petersonmarco@yahoo.com.br

Insights

This study identified key functioning and disability items in pediatric cerebral palsy (CP) rehabilitation records. Findings suggest a need for standardized International Classification of Functioning, Disability and Health, Children and Youth Version (ICF-CY) use for consistent documentation.

Area of Science:

  • Pediatric Rehabilitation
  • Child Development
  • Disability Studies

Background:

  • Cerebral palsy (CP) significantly impacts child development and requires interdisciplinary rehabilitation.
  • Standardized documentation is crucial for effective patient care and research in pediatric rehabilitation.

Purpose of the Study:

  • To identify frequently documented functioning and disability-related items by rehabilitation professionals for children with CP.
  • To evaluate the completeness and consistency of patient records using the International Classification of Functioning, Disability and Health, Children and Youth Version (ICF-CY).

Main Methods:

  • A retrospective cross-sectional study analyzed medical documents from 40 children with CP (aged 10 months–17 years).
  • Two raters extracted data using 27 ICF-CY items to assess functioning, disability, and environmental factors.
  • Records from physicians, physiotherapists, occupational therapists, speech therapists, social workers, psychologists, and dieticians were reviewed.

Main Results:

  • Eighty-one items related to functioning and disability were identified across body structures, functions, activities, and environmental factors.
  • Physiotherapy and occupational therapy records were the most comprehensive.
  • Fourteen ICF-CY categories met a minimum frequency of 40% in documentation.

Conclusions:

  • Rehabilitation records for children with CP contain heterogeneous information on functioning and disability.
  • The most frequent items identified could form a basis for CP triage codes.
  • Establishing interdisciplinary consensus on ICF-CY use is essential for systematic record-keeping.
Abstract