Clinical Documentation using ICF for a 12 years old Child with Cerebral Palsy- A case Study Approach.

Abstract

Cerebral Palsy (CP) is a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The purpose of the study was to present a framework for developing an ICF-based documentation system in Cerebral Palsy rehabilitation across the continuum of care by using a case study approach. A Case Report of a 12-year-old boy suffering from chore-athetoid cerebral palsy since birth. The report describes the integration of the ICF-based documentation tools into the patient’s examination, evaluation, prognosis, diagnosis, and intervention while he participated in a physiotherapy rehabilitation program for 4 months and the outcome measures used were GMFM and UFMG SYDENHAM’S CHOREA RATING SCALE at the baseline and after 4 months. The ICF-based documentation for physical therapists summarizes all relevant information to aid the physical therapist’s patient management. It also demonstrates, a viable framework both for physical therapy and multidisciplinary management and for clinical documentation.