Compiling standardized information from clinical practice: using content analysis and ICF Linking Rules in a...

Area of Science:

• Rehabilitation Medicine
• Health Informatics
• Disability Studies

Background:

• Narrative reports in rehabilitation programs often lack standardization.
• Chronic neurological conditions in youth require comprehensive and consistent health documentation.
• The International Classification of Functioning, Disability and Health (ICF) offers a standardized framework for health information.

Purpose of the Study:

• To demonstrate the transformation of routine narrative rehabilitation reports into the ICF.
• To assess the feasibility of using ICF Linking Rules for this transformation process.
• To explore the potential for standardizing health information in pediatric rehabilitation.

Main Methods:

• Qualitative content analysis of narrative admission and discharge reports.
• Structuring reports using the Rehab-Cycle framework (goal, assessment, assignment, intervention, evaluation).
• Linking meaningful units to the ICF using refined ICF Linking Rules.

Main Results:

• Transformation yielded a process-oriented, interdisciplinary layout with three thematic goal blocks: mobility, self-care, and mental/social functions.
• 95 unique ICF codes were identified and grouped into clinically meaningful, goal-centered codes.
• Improved agreement rates between independent linkers after refining the ICF Linking Rules.

Conclusions:

• ICF Linking Rules can standardize health information from narrative reports, though requiring time and expertise.
• The Rehab-Cycle provides a feasible framework for structuring rehabilitation programs.
• Refined ICF Linking Rules enhance the standardization and transparency of rehabilitation reporting, supporting international standards.