Documenting Activities

After reading this chapter and completing the exercises, the reader will be able to:

2. Discuss the factors involved in deciding which activities should be included in documentation.

3. Identify and classify various aspects of documenting activities.

4. Appropriately categorize activities of daily living and instrumental activities of daily living.

5. Document activities using a skill-based framework.

Defining and Categorizing Activities

This chapter discusses documentation and categorization of Activities (Figure 7-1). Activity as defined by ICF is the execution of a task or action by an individual. Many therapists typically refer to this as function, functional ability, functional status, or functional activities. As discussed in Chapter 1, the ICF has an inherently positive approach toward disablement. Thus therapists should be encouraged to document those activities a person is able to perform. In most cases, documentation should include abilities and limitations as they relate to function. However, the primary purpose of the ICF is to shed a positive light on disablement. In this book, we use the term Activities, in accordance with ICF terminology, as a global category for documenting skills, abilities, and limitations related to function.

FIGURE 7-1 This chapter discusses documentation pertaining to limitations in Activities, based on the ICF framework.

The term function is typically used by rehabilitation professionals to describe a person’s performance of skills or tasks that are pertinent to his or her daily life. Function can be defined as “the action for which a person is fitted or employed” (Davis, 2000). If an action is to be considered functional, it must (1) be meaningful to an individual and (2) help an individual to fulfill his or her roles (e.g., spouse, parent, volunteer, worker, student, pet owner).

In the current edition of the Guide to Physical Therapist Practice, the list of tests and measures is not distinguished based on Participation, Activities, and Body Structures and Functions. Rather, the tests and measures are listed alphabetically, which is not necessarily conducive to providing a logical organization for a patient evaluation (Gordon & Quinn, 1999). Five of the 24 groupings in the list of tests and measures presented in the Guide have components that measure functional abilities:

• Aerobic capacity and endurance

• Gait, locomotion, and balance

• Neuromotor development and sensory integration

• Self-care and home management (including activities of daily living [ADLs] and instrumental activities of daily living [IADLs])

• Work (job/school/play), community, and leisure integration or reintegration (including IADLs)

In several of these categories the differentiation between Body Structures and Functions and Activities is difficult, as in the case of “gait, locomotion, and balance.” The task of walking is certainly an activity, but describing the details of the gait pattern or the balance needed to maintain walking is more closely related to impairment of body functions. In fact, the differentiation between impairments and activities may be considered as a continuum rather than a strict separation. Figure 7-2 and Box 7-1 illustrate this concept. This continuum is discussed in more detail below.

BOX 7-1 The Gray Line Between Activities and Impairments in Body Structures/Functions

As mentioned in Chapter 1, the ICF model affords different perspectives to describe physical therapy patients and their conditions. A patient’s condition can be described in terms of the health condition, body structures and functions, activities, or participation. These are not separate and distinct characteristics of the patient; they are all aspects of the same disabling condition, described in different measurement systems. Furthermore, some overlap occurs between levels of the ICF model. For example, the classification of an evaluation finding as an impairment versus an activity limitation, and between and activity limitation and participation, is often a slightly gray area.

The crucial distinction between impairments and activity limitations is between means and ends. Activities are described in terms of goals or ends. The impairment level describes means to an end: by what mechanisms the goal is accomplished. This important distinction can be illustrated with reference to two movement systems: balance and walking.

Balance

Balance is a perfect example of a characteristic that is difficult to categorize. In its purest sense, balance is described at the impairment level, reflecting the ability of an individual to maintain an upright position against gravity. However, balance is often evaluated through a set of tasks that might be considered “functional.” For example, the ability to stand in one place for more than 30 sec is certainly an activity, as is the ability to reach to the floor to pick up an object. Thus if balance is described in terms of the goal, it is an activity. If it is analyzed in terms of the component mechanisms (e.g., increased sway, role of vision), then it is at the impairment level.

Walking

Walking is another example of a task that combines both impairments and activity limitations. Therapists often describe walking in functional terms—how long a patient can walk, how quickly, with how much assistance. However, another important component of walking is evaluation of how a person walks—his or her gait pattern. Gait analysis can be considered a measure at the impairment level. Therapists often describe gait deviations (such as a Trendelenburg gait) that reflect the presence of an underlying impairment (gluteus medius weakness). Again, if the walking is measured in terms of goal attainment (e.g., distance, speed), then it is a function. If gait is analyzed in terms of why the goal is not being achieved (e.g., insufficient knee flexion during swing or inadequate stance phase control of knee extensors), then walking is being described in terms of impairments.

Classification

Even more problems arise in classification of standardized tests and measures. Standardized tests sometimes measure across different levels of the ICF framework (e.g., measuring some components of activities and some of impairments). This in fact may be desirable when a global standardized test is needed.

These difficulties with classification and distinction may seem academic, but documentation can be frustrating if therapists are searching for clear-cut answers (e.g., Is balance an activity or an impairment?). The following strategy is suggested.

All information about a topic (e.g., standing ability, balance control) should be included under one subheading (e.g., standing balance). Even if a particular topic mixes function and impairments, cohesive presentation of that information in the written report is of primary importance (see Case Example 7-1, where standing and sitting ability include components of a balance assessment). Reading a report with information about a single component scattered throughout the report is difficult. Whether the information is categorized under “activities” or “impairments” can depend on the focus of information being written.

FIGURE 7-2 This task space represents the interface between body structures and functions and activities. Tasks can have stronger components of either activities or body functions depending on the nature and goal of the task.

Activities are arguably the most important component of physical therapy documentation, particularly when they pertain to function. Performance in functional activities is used to justify the need for physical therapy services as well as to show a patient’s improvement over time. From a PT’s perspective, health conditions and the resulting impairments are important insofar as they affect a patient’s daily functioning. Functional activities are those that are meaningful to patients: Can they walk, run, get dressed, reach, and grasp for objects? Improvements in these activities should be a primary outcome of physical therapy intervention.

Documenting Task Performance

Physical therapy intervention often entails practice of specific actions, such as walking, squatting, lifting, reaching, and grasping. In effect, these actions are tasks that are used in a wide range of activities. Therapists often quantify and qualify performance on tasks as a measure of a patient’s functional ability. Reaching, grasping, walking, and many other types of movement patterns are elements of functional activities; they are not functional activities per se. They are not considered activities because they do not have a clearly definable and meaningful goal or purpose. For instance, gait evaluation describes the movement patterns used for walking. Gait deviations (e.g., Trendelenburg, excessive circumduction, foot drop) are therefore impairments. Walking to the bathroom and walking outside on grass to move through a yard describe activities because they have a meaningful goal. As stated earlier, functions are actions that are meaningful to an individual and help an individual to fulfill his or her roles in life. In certain situations, documentation of a patient’s performance of tasks outside the context of specific functional activities may be useful. For example, a therapist could document a person’s ability to reach forward into space or to take steps in the parallel bars. For documentation purposes, such elemental tasks are most logically reported in the Activities section of the report.

Tasks represent the interface between activities and body structures and functions (see Figure 7-2). Evaluation of the movement patterns and strategies used to perform such tasks provides important insight into the underlying impairments that affect activities. Task evaluation may bridge many functional skills. For example, the ability to squat is an important task for functional activities ranging from using the bathroom to picking up an object. Importantly, therapists may use task analysis to derive a deeper understanding of the contribution of various impairments to activity performance. Documentation of tasks therefore often includes information about how the movement was performed and the effect of any impairments on functional performance.

Although evaluation of task performance is an important aspect of the physical therapy evaluation process, therapists should give priority to context-based activity assessment. For example, tasks such as reaching and grasping often can be assessed within the context of a functional activity, such as eating or brushing teeth. A person’s ability to perform reaching and grasping behaviors is affected by the context in which they are performed (e.g., in a sitting or standing position). Similarly, assessment of gait abnormalities may differ depending on the context in which walking occurs (e.g., walking on tile vs. carpeting).

Documenting Performance of Functional Activities

One of the important roles of a PT is to determine which activities are meaningful to a specific individual and help that person achieve independence and skill in these activities. Many possible activities could be important for an individual. Pertinent functional activities are those that are related to a person’s specific life roles and relevant to the patient’s therapeutic goals. Functional activities can be categorized in each of the three life roles: personal, occupational, and leisure. Some activities are common to almost everyone. Other activities are more specific to a person’s life roles, such as those required for work or recreational sports.

Box 7-2 presents examples of common activities related to personal, occupational, and leisure roles. Personal Activities are further divided into ADLs and IADLs. ADLs are the basic tasks of everyday life—eating, dressing, bathing, and so on. IADLs are not necessarily critical for everyday functioning but are important for independent functioning within a community—answering the telephone, managing finances, and so on. This list can be used as a guide to documentation of activities. PTs can create subheadings within this section of the report to better organize the information and improve readability (Case Examples 7-1, 7-2, and 7-3). It is often useful to group activities or tasks together (e.g., ambulation or transfers) and include all related tasks under their appropriate headings.

BOX 7-2 Documenting Activities: A Suggested List of Activities Related to Personal and Occupational Roles *

Personal Activities

Activities of Daily Living