Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health During multidisciplinary patient management. Phys Ther 2010; 90

Background and Purpose. Physical therapists require a comprehensive as-sessment of a patient’s functioning status to address multiple problems in patients with severe conditions. The International Classification of Functioning, Disability and Health (ICF) is the universally accepted conceptual model for the description of functioning. Documentation tools have been developed based on ICF Core Sets to be used in multidisciplinary rehabilitation management and specifically by physical therapists. The purposes of this case report are: (1) to apply ICF-based documentation tools to the care of a patient with spinal cord injury and (2) to illustrate the use of ICF-based documentation tools during multidisciplinary patient management. Case Description. The patient was a 22-year-old man with tetraplegia (C2 level) who was 5 months postinjury. 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 multidisciplinary rehabilitation program for 2 months. Outcomes. The patient’s comprehensive functioning status at the beginning o