Documentation Basics for the Physical Therapist Assistant

After reading this chapter, the reader will be able to do the following: 1. Define disablement. 2. Define terminology used in the International

Classification of Functioning, Disability and Health (ICF).

3. Differentiate between impairment, activity limitation, and participation restriction.

4. Define documentation. 5. Describe the need for common language in physical

therapy documentation. 6. Describe how disablement concepts can be integrated

into physical therapy documentation. A traditional approach to defining a person’s health

comes from the biomedical model in which health means free or absent from disease.1 The biomedical model implies that accurate diagnosis and identification of the patient’s biological defects can directly lead to selection of interven- tions that will maximize health outcomes.1 In this model, however, there is little emphasis on how the disease affects

the person’s ability to function or participate within society on a daily basis. Documentation Basics for the Physical Therapist Assistant

Over the last few decades, many reha- bilitation professionals have shifted their focus away from managing the disease or pathology and have moved toward managing the consequences of the disease or condition. It has become more common to focus on these consequences as they pertain to the individual’s ability to carry out tasks and function within society. Assessing functional perfor- mance and describing functional status are now primary components of the physical therapist’s examination of the patient. Verbrugge and Jette2 described the consequences that chronic and acute conditions have on specific body system function and on a person’s ability to act in neces- sary, usual, expected, and personally desired ways in his or her society as disablement. These authors explained that disablement is a “process,” indicating that it is dynamic, or a trajectory of functional consequences over time. A more contemporary approach to physical therapy patient man- agement is to incorporate disablement and disablement concepts. Documentation Basics for the Physical Therapist Assistant

Individuals and groups throughout the world have developed disablement frameworks. Disablement frame- works are useful for providing a common language for health care providers, and they can serve as a basic archi-

CHAPTER OBJECTIVES

KEY TERMS Activity | Activity limitation | American Physical Therapy Association | Biomedical model | Body functions | Body structures | Contextual factor | Disablement | Documentation | Environmental factor | International Classification of Functioning, Disability and Health | International Classification of Diseases, Tenth Revision | Participation | Participation restriction | Personal factor | Physical therapist Documentation Basics for the Physical Therapist Assistant

KEY ABBREVIATIONS APTA | ICD-10 | ICF | PT | WHO

Chapter 12

tecture for research, policy, and clinical care.2 In addi- tion to providing infrastructure, disablement frameworks define health in terms that go beyond the patient’s medical diagnosis or disease, acknowledging the importance of societal, psychological, and physical functioning. Rather than placing the measure of health on the disease process itself, these models have helped providers to shift toward understanding an individual’s ability to carry out neces- sary life tasks and to function within society. Disablement frameworks have attempted to delineate a pathway from pathology to functional outcome while recognizing the social, psychological, and environmental factors that can facilitate or interfere with the pathway.2 The purpose of this chapter is to introduce you to the disablement frame- work used in physical therapy practice and to introduce the purpose of using disablement and disablement concepts in clinical documentation. Documentation Basics for the Physical Therapist Assistant

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH

The ICF, originally known as the International Classification of Impairments, Disabilities, and Handicaps, was endorsed by the 54th World Health Assembly and released in 2001. The ICF provides a uniform, standard language for describing an individual’s health and health- related state that moves beyond his or her diagnosis.3 In 2008, the American Physical Therapy Association (APTA) House of Delegates voted to endorse the ICF and, as a result, APTA publications, documents, and communications have been updated to incorporate the ICF language (Example 1-1).4 Therefore, the ICF serves to provide a common lan- guage for physical therapists to communicate. Documentation Basics for the Physical Therapist Assistant

Example 1-1 The following definitions have been endorsed by the World Health Organization as part of the ICF3:

• Functioning is an umbrella term that includes all body functions, activities, and participation. • Disability serves as an umbrella term for dysfunction at any one or more of the following levels: impairment, activity limitation, and participation restriction.

• Body functions are physiological functions of the body (including psychological function). • Body structures are anatomical bodily structures, such as organs and limbs. • Impairments are problems with body functions (physiological, psychological) or structures, such as a deviation or loss.

• Activity is the execution of a task or activity by an individual. • Activity limitations are difficulties that might be encountered by an individual who is attempting to complete a task or carry out an activity. Documentation Basics for the Physical Therapist Assistant

• Participation is involvement in a life situation, such as work or school. • Participation restrictions are problems an individual might face while involved in life situations.

• Contextual factors are the complete factors that make up a person’s life and living, including his or her background.

• Environmental factors are the physical, social, and attitudinal environmental in which people live and carry out their lives. These include things immediate to the individual, such as his or her home or workplace, and the larger social context, such as government agencies designed to assist people with disabilities.

• Personal factors are factors specific to the individual and his or her background. These include things such as age, gender, social habits, health habits, upbringing, and coping strategies. Documentation Basics for the Physical Therapist Assistant

Disablement and Physical Therapy Documentation 3

In the ICF, the individual’s health or health-related state is described in terms of function and disability. What the individual can do is known as functioning, or the positive aspects of health. What the individual cannot do is known as disability, or the negative aspects of health (Figure 1-1).3 Function and disability comprise Part 1 of the ICF. Part 1 is further divided into the following 2 components: (1) body functions (physiological function) and body struc- tures (anatomical structures) and (2) activities and partici- pation (Figure 1-2).3 In categorizing an individual’s health according to the ICF, a health care provider would describe body structures and functions that are intact and those that are not intact. Any deviation(s) from normal body structure and/or function are known as impairments. For the activities and participation component, the exam- iner identifies functional tasks that the individual can do (known as activities) and those that he or she cannot do (known as activity limitations). The examiner also identi-

fies life roles that the individual can carry out (known as participation) and those that he or she cannot carry out (known as participation restrictions; see Figure 1-1).3

ORDER A PLAGIARISM FREE PAPER NOW

The ICF also accounts for contextual factors that might facilitate or impede the patient’s function. These appear in Part 2, which also includes environmental and personal factors that affect the individual’s functioning and dis- ability. Environmental factors are external factors that are either within the individual’s immediate environment or part of a larger social structure and that affect the individual’s ability to participate in society. These might be facilitators, which enhance participation, or barriers, which deter participation. Environmental factors include things such as physical structures (eg, ramps, stairs, curbs). Personal factors are those that are unique to the individual, such as attitude, mood, or family support (see Figure 1-2).3 Documentation Basics for the Physical Therapist Assistant

Figure 1-1. Overview of the International Classification of Functioning, Disability and Health.3 The string of boxes on the left repre- sents the positive aspects of the health state or condition. The string of boxes on the right rep- resents deviations from normal, or the negative aspects of health.

Body-level

Individual- level

Societal- level

ICF

Health and Health- Related States

Function: What the individual

CAN do (Positive Aspects of

Health)

Disability: What the individual

CANNOT do (Negative Aspects

of Health)

Body tissues and/ or structures that

are intact and functioning

(Normal)

Body tissues and/ or structures that are not intact or

functioning (Impairments)

Tasks an individual CAN carry out

(Activities)

Tasks an individual CANNOT carry out

(Activity Limitations) Documentation Basics for the Physical Therapist Assistant

Roles in which an individual CAN

participate (Participation)

Roles in which an individual CANNOT

participate (Participation Restrictions)

Chapter 14

The ICF is part of a “family” of classifications created by the World Health Organization (WHO) known as the WHO Family of International Classifications.5 This family also includes the International Classification of Diseases, Tenth Revision (ICD-10), a classification system for medical diagnoses and diseases. The ICD-10 is the diagnostic clas- sification standard for all clinical and research purposes. It defines the universe of disease, disorders, injuries, and other related health conditions, listed in a comprehensive format.6 The ICF and ICD-10 are meant to complement each other in that the ICD-10 provides a catalog of medical diagnoses, diseases, disorders, and health conditions and the ICF provides corresponding information on function and disability. Used together, they provide a broader picture of an individual’s health.7 Documentation Basics for the Physical Therapist Assistant

PHYSICAL THERAPY AND DISABLEMENT The ICF provides clinicians with standardized termi-

nology and a framework to aid in exploring the impact of disease or injury on an individual’s daily life. More spe- cifically, physical therapy providers can use the ICF to help understand the consequences of the disease or condition on the body systems and the impact on the individual’s activ- ity level and participation within society. Consideration

of disablement when working with patients helps physical therapy providers to realize more complex functional and social issues that patients face.

Individuals in need of physical therapy services often have a disease or injury with resulting impairments in body structure(s) and/or function(s), activity limitations, and participation restrictions that are identified during the physical therapist’s examination. Impairments can be limitations in range of motion, strength, endurance, or balance, to name a few. But to see how the patient’s abil- ity to participate in society has been compromised, the examination must go beyond the impairment level. It is our responsibility to understand how impairments affect the patient’s day-to-day activities and participation in a variety of settings and situations; therefore, the physical therapist’s examination of patient function includes assessment of the following: (1) activities such as bed mobility, transfers, hygiene, self-care, and home management (eg, yardwork, household cleaning); and (2) participation such as the abil- ity to work, go to school, play, and participate in commu- nity activities (eg, going to the grocery store or bank). By understanding an individual’s impairments and his or her activity limitations and participation restrictions, we can better understand the degree of disability associated with the pathology for the individual patient Documentation Basics for the Physical Therapist Assistant