Content identification of the interdisciplinary assessment of cerebral palsy using the International Classification of Functioning, Disability and Health as reference.

PURPOSE: To identify relevant items and most frequents categories related to functioning and disability recorded by professionals involved in rehabilitation of children with cerebral palsy (CP) and to assess the filling of the records.

METHODS: A retrospective cross-sectional study based on the written documents provided by an interdisciplinary rehabilitation team. Participated in the study 40 patients with CP, aged 10 months to 17 years. Two raters extracted information from the patients' medical documents as recorded by physicians, physiotherapists, occupational therapists, speech therapists, social workers, psychologists and dieticians using the ICF-CY. Patients' records were scored (+functioning, -disability and *environmental factors) using 27 ICF-CY items to assess the filling of the records.

RESULTS: Eighty-one items in the medical records [body structure(15), bodily functions(32), activity(24) and environmental factors(10)] were identified as related to the evaluation of the different professions involved with neuro-rehabilitation. Physiotherapy and occupational therapy provided the most comprehensive assessments performed. Fourteen categories had a minimum frequency of 40% during the registration process.

CONCLUSIONS: The content of the information involves categories related to the structures and body functions, activities and environmental factors. The information follows a heterogeneous pattern in content and number of categories. The most frequent items can comprise a set of codes for triage of CP. It is necessary to establish an interdisciplinary consensus based on ICF-CY for systematize the information's record.