Content Analysis of ICF-Based Data in the Multidisciplinary Health Records of People With Spinal Cord Injury.

Background The International Classification of Functioning, Disability and Health (ICF) was developed by the World Health Organization as a standard language to describe biopsychosocial aspects of functioning, health, and health-related states. Different health professionals document functioning data from their professional perspective.

Objectives The primary objective of this study was to utilize multidisciplinary electronic health records to identify the factors considered significant by different healthcare professional groups in documenting the functioning, disability, and health of individuals with spinal cord injury (SCI).

Methods A random sample of 10 patients was selected from a larger cohort (n = 49) for analysis. Free text from electronic health records regarding subacute inpatient rehabilitation and an outpatient visit at the chronic stage was collected. Two researchers annotated the data to ICF codes. The study was a descriptive, longitudinal study using quantitative content analysis. Contextual analysis was used to compare the data between different health professionals and at different time points.

Results In the 10-patient random sample, 447 health records were retrieved. The functioning data consisted of all ICF domains, with 9349 findings. Environmental factors were documented the most. Health professional groups had different patterns in the frequency of documented ICF categories in their documents, reflecting professionals' expertise in the multidisciplinary team. For example, occupational therapists highlighted activities and participation whereas psychologists emphasized body functions.

Conclusion The findings of this study may facilitate the development of rehabilitation for persons with SCI and highlight the importance of multidisciplinary rehabilitation in complex medical conditions.