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Clinical physiotherapy documentation in stroke rehabilitation: an ICIDH-2 Beta-2 based analysis

Purpose: To explore the focus of physiotherapists practising in stroke rehabilitation, through identification of central elements in clinical physiotherapy documentation. Method: A descriptive study in which the Motor Assessment Scale for Stroke (MAS) and 20 physiotherapy records were collected from the stroke unit of a rehabilitation hospital and classified according to the ICIDH-2 Beta-2. The text was broken down into single units of functional descriptions and assigned classification codes. The coded units were counted and the distribution of the units on the ICIDH-2 Beta-2 examined. Results: In the physiotherapy records the majority of coded units belonged to the dimension of Body Functions, particularly to b7 Neuromusculoskeletal and movement related functions. In the MAS two thirds of the units belonged to Activities, with a3 Movement activities as the major group. There were no units related to Participation or Environmental Factors. Conclusions: Physical functioning and movement were the central elements in this sample of clinical documentation, thus confirming earlier perception of physiotherapy. Lack of documented information on participation and environment could have several reasons. However, physiotherapists in stroke rehabilitation may consider if patients' environment and participation in life situations should have a larger place in clinical physiotherapy.