Toward a framework for developing an ICF-based documentation system in spinal cord injury-specific rehabilitation...

Area of Science:

• Rehabilitation Medicine
• Health Informatics
• Disability Studies

Background:

• Standardized documentation is essential for effective spinal cord injury (SCI) rehabilitation.
• Existing assessment tools often lack comprehensive coverage of functioning domains.
• The International Classification of Functioning, Disability and Health (ICF) provides a standardized framework for describing health and functioning.

Purpose of the Study:

• To present a framework for developing an ICF-based documentation system tailored for SCI rehabilitation.
• To evaluate the coverage of ICF categories by existing clinical assessment tools in SCI care.
• To describe rehabilitation services within the SCI continuum of care.

Main Methods:

• A case study approach was used with data from four SCI patients across different care phases.
• ICF linking rules were applied to patient interviews and health records.
• ICF categories identified were compared against established ICF sets (Generic-30, SCI/MS core sets).

Main Results:

• Clinical assessment tools covered less than half of the relevant ICF categories, particularly in acute and long-term phases.
• Activities, participation, and environmental factors were least covered.
• Incorporating patient interview data significantly improved ICF category coverage.

Conclusions:

• There is a critical need for systematic and standardized functioning assessments in SCI rehabilitation, especially in developing countries.
• This study provides foundational steps for an ICF-based system to assess and report functioning outcomes in SCI rehabilitation.
• The proposed framework aids in standardizing documentation and improving care across the SCI continuum.