Electronic health record data extraction: Physical therapists' documentation of physical activity assessments and prescriptions for patients with chronic low back pain.

Abstract

Background: Despite physical activity being a major component of managing chronic low back pain, < 50% of patients receive physical activity interventions. Electronic Health Records can deepen our understanding about this clinical gap.

Objective: We aimed to: 1) develop and test a data abstraction form that captures physical activity documentation; and 2) explore physical therapists' documentation of physical activity assessments and interventions.

Methods: We developed a data abstraction form using previously published practice guidelines. After identifying the forms' inter-rater reliability, we used it to explore physical therapists' documentation related to physical activity assessments and interventions for patients with chronic low back pain.

Results: The final data abstraction form included information about physical activity history, assessments, interventions, general movement discussion, and plan. Our inter-rater reliability was high. Of the 18 patients, 66.7% had documentation about their PA history. Across the 56 encounters, 14 (25.0%) included an assessment, 18 (32.1%) an intervention, 18 (32.1%) a general movement discussion, and 12 (21.4%) included a plan.

Conclusion: Using our reliable data abstraction form we identified a lack of documentation about physical activity assessments and interventions among patients with chronic low back pain. A larger study is needed to examine the generalizability of these results.