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KMID : 0357220150270060392
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Journal of Korean Society Physical Therapy
2015 Volume.27 No. 6 p.392 ~ p.399
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Which Information is Commonly Used for Patients with Stroke at Rehabilitation Settings?
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Lee Hae-Jung
Song Ju-Min
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Abstract
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Purpose: To explore the functioning information in the current medical records for patients with stroke using the comprehensive International Classification of Functioning, Disability and Health (ICF) coreset for Stroke.
Methods: Physical therapists, who have more than 3 years of clinical experience in neurologic therapeutic area, filled out the coreset for Stroke based on their patients’ medical records, and an interview was conducted for them. Each of the categories in the coreset was analyzed using frequency and percentage analysis.
Results: A total of ninety patients with stroke were evaluated. Five categories of neuromusculoskeletal and movement functions in the body function domain were rated as having problems in over 90% of the patients. Four categories of the body structure domain were found as having a problem in over 73% of patients. In the domain of activity and participation, eight categories related to function of domestic lives, areas of major life and mobility were identified as having a problem for more than 90% of those patients. In the environmental factors, a category of health professionals was documented as facilitator in 87% of patients whilst nine categories, including products and technology, physical geography, services, systems and policies, were rated as barriers by more than 10% of patients.
Conclusion: The current medical records of patients with stroke contain functioning information. Information regarding body function, and activity and participation was mainly focused on rehabilitation services. It is suggested that environmental factors should be included to understand patients’ life situation which may have impact on patients’ functioning.
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KEYWORD
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ICF, Stroke, Medical recordings
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