ICF를 적용한 뇌졸중 환자의 문서 기록과 중재 전략의 실례

A case report of the intervention strategy & documentation in a patient with post stroke applied a International Classification of Functioning, Disability and Health

Background and Purpose : Many Physical therapist are inclined to communicate less effectively each other because they hardly use the standard terminology. The purposes of this case report are (1) to apply ICF-based documentation in evaluation (2) to submit the strategy of intervention process to improve the ability of walking short distance of the client who has post-stroke. Description : The client was 44-years-old man with hemiplegia who was in 1 month post-stroke problems were diagnosed while applying the ICF core set. The goals agreed with client were independently walking short distance, stairs and obstacles. To come up with the intervention strategy, hypothesis was set and 4 weeks of intervention was carried out after proposing the short goal and detailed purpose. Outcome : The client's performance in walking short distance and confidence were increased after impairment focused intervention, that are improved in walking velocity, endurance, supporting ability in lower limbs, rhythmical movement in upper limbs and the coordination of both limbs. Activities focused intervention also enhanced the ability in climbing steps and walking around obstacles. Conclusion : The decided hypothesis and goal that are to solve the problems the client faced were remarkably meaningful.