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

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.