Information on functioning found in the medical records of patients with stroke.
Haejung Lee, Sunghwa Seo, Jumin Song
PMID 27821922WHAT IT FOUND
Stroke admission and discharge summaries mostly captured body function information, including muscle power and pain, and also walking, medication and imaging, while social participation and hobbies were absent.
Key findings
01The records contained 1,832 functioning items linked to 85 ICF categories, with 52.94% in body function, 22.35% in activity and participation, 16.47% in body structure, and 8.24% in environmental factors.
02The most commonly reported information was pain, prescribed drugs or medication, health services including referrals, brain structures on imaging such as CT or MRI, and walking difficulties.
03Information about social participation, such as interpersonal relationships and engaging in hobbies, was not found in the current records.
STILL TO COME
How it was doneWhat they foundWhat it means for PTsWhat it means for OTs
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What it does not show
Only 30 patients' admission and discharge summaries were reviewed, so the findings may not apply to other hospitals or to stroke records with different formats. The study used three university hospitals in South Korea, where specialist consultations and concurrent medical conditions were common, which may make the records look more medical than therapy-focused. The summaries were structured, and the study looked only at what was already recorded, not at information patients may have discussed but not documented. The study did not test whether linking records to the ICF improves patient care or rehabilitation outcomes.
The easy way to misread this
Do not read this as evidence that ICF-linked documentation improves patient care. It only describes what was already present in the admission and discharge summaries of 30 stroke patients, not whether adding categories changes outcomes.