DISABILITY AND REHABILITATION,
2003;
VOL.
25,
NO.
11–12, 620–627
Past and future use of the ICF (former ICIDH) by nursing and allied health professionals YVONNE HEERKENS{*, YPE VAN DER BRUG{, HUIB TEN NAPEL} and DORINE VAN RAVENSBERG{ { Dutch National Institute of Allied Health Professions, Amersfoort, The Netherlands { Academic Medical Center, University of Amsterdam, The Netherlands } University of Nijmegen, Department of Medical Informatics, The Netherlands
Abstract Purpose: This study describes the use of the ICIDH by allied health professionals and the nursing professions in The Netherlands. It is an example for showing how in recent years the application of the ICIDH has developed within professions. The data elements of patient descriptors documented by nurses and allied health professionals using the ICIDH, as a shared terminology, are presented. Method: The study contains an overview of former and present application of the ICIDH and a systematic description of (possible) use of the ICIDH and its successor, the ICF. Results and conclusion: Although former and present use prove to be valuable, the level of detail needed for a richer description of the functioning of a patient does not yet exist within the ICIDH nor within the ICF. This and other arguments are given for the innovation process of the ICF and the need for the development of a (multidisciplinary) clinical modification, the ICF-CM.
INTRODUCTION For nurses and allied health professionals{ it is important to know aspects of the medical status of the patient. The disease the patient is labelled with, the medical procedures carried out, and the provided medication contain relevant information. However, these data are not the main points of interest for nursing and allied health professionals. In the treat-
* Author for correspondence; e-mail:
[email protected] {In The Netherlands the following professions are indicated as ‘allied health professions’: chiropodists, dieticians, exercise therapists, occupational therapists, physical therapists, oral hygienists, orthoptics, radiological therapists and speech therapists.
ment given by these professionals disease is not the central issue; in many cases the therapy is not directed – directly – to curing the patient. For example, aims of physical therapists and exercise therapists are, amongst others, to help the patient improve the movement functions, to reduce pain, to work on an increase of muscle strength and coordination, and to improve motor activities like sitting and walking. Occupational therapists are involved in improving the activities of daily living and activities related to work, school and leisure, including the process of applying the relevant technical aids. Speech therapists are involved in training the functions of language/ voice/speech and communication activities, and nurses monitor and support functions, and guide or take over several of the daily activities of patients when they cannot perform, or are not allowed to perform, these activities themselves. It is therefore clear that for communication and for the registration of goals and results of the diagnostic and therapeutic process, medical terminology alone is not sufficient. More than, and next to medical diagnostic terminology, these professions need terminology to describe the ‘functional status’ of the patients which receive their shared care. It is therefore not remarkable that during the process of enhancing the transparency of these professions – necessary in improving the quality of care given – there has been a search for such a terminology. During this process the ICIDH1 was discovered and subsequently embraced as a terminology that fulfilled their shared need. In the period 1986 – 1992 the first Dutch experiments took place in which the ICIDH was used for the description of the health status of patients visiting a physical therapist. These experiments were soon followed by several other applications of the ICIDH, both by physical therapists
Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2003 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/0963828031000137135
Past and future of the ICF as well as by other allied health professions and nursing. ADAPTED VERSIONS OF THE ICIDH
A number of adapted Dutch versions of the ICIDH are published to meet the needs of various professions, some based on the 1980 version of ICIDH and some on the Beta-1 draft (see table 1). At this moment these adapted Dutch versions of the ICIDH are used for several purposes (see ‘overview of former and present applications’). Characteristic for the Dutch adaptations is the higher level of detail. Many classes were added because the terminology of the ICIDH is considered not specific enough to describe the problems of functioning of the clients involved. The content of the Classification of Diagnostic terminology for Nursing (CDV)2 is based on the 1980 version of ICIDH and early proposals for the ICIDH-2 draft,3 in combination with the Functional Health Patterns of Gordon (FHP)4 as an overall framework. Now, 6 years later, the general feeling is that this ‘Gordon-ICIDHsystem’ as well as other existing classifications for nursing care are unsatisfactory.5, 6 It is becoming clear that these profession specific terminologies form an obstacle for communication with other disciplines. DATA WHICH CAN BE CLASSIFIED WITH THE ICIDH/ICF
In table 2 an overview is given of the process of care given by nurses and allied health professionals. In this table the relevant data elements are indicated, including the classifications which can be used to register these
data elements. What becomes clear from this table is that the ICIDH – and the new ICF12 – is an important classification. It can be used for the description of several crucial data in the process of care, such as patient’s findings, findings of professionals, elements of the diagnosis formulated by these professionals, treatment goals and treatment results. It is therefore not remarkable that ICIDH-terminology is used since 1990 in research and development of these professions. OVERVIEW OF FORMER AND PRESENT APPLICATIONS
In this overview examples are given of former and present use of the ICIDH in the Netherlands. Only some of the Dutch projects are available as English publications. The present overview is far from exhaustive and is meant to give an impression of the use of the ICIDH/ ICF by nurses and allied health professionals. .
(electronic) registration systems, e.g. – an information system for speech therapists (LIS); in this electronic system the diagnosis formulated by the speech therapist can be classified using the Dutch adaptation of the ICIDH for speech therapy;18 – an electronic information system for dieticians in university hospitals; this software – which is now being tested – contains selections of the four draft classifications available for dieticians, including the draft version of the ICIDH for dieticians (see table 1);
Table 1 Adapted (more detailed) Dutch versions of the ICIDH for use by nurses and allied health professionals Profession(s)
Author(s) and year of publication 7
Name of the adapted classification
Version of the ICIDH
Chiropody exercise therapy occupational therapy physical therapy
van Ravensberg et al. 1995
Adaptation of the ICIDH: impairments/functions and disabilities/activities
ICIDH-1980
Speech therapy
WCC, 19948
Application of the ICIDH in speech and language therapy
ICIDH-1980
Nurses
Ten Napel, 19962
Classification of Diagnostic terminology for Nursing (CDV)
ICIDH-1980/Alpha-draft
Speech therapy
Heerkens et al. 19989
Draft version of the ICIDH for speech therapy
Beta-1 draft
Dieticians
Beens and Heerkens, 199910
Draft version of the ICIDH for dieticians
Beta-1 draft
Oral hygienists
Corbey and Heerkens, 199911
Draft version of the ICIDH for oral hygienists
Beta-1 draft
621
622
Ô
Ô
Ô
Ô
Ô
Ô
Ô
Ô
2 History taking
3 Examination
4 Analysis
5 Treatment plan
6 Treatment
7 Evaluation
8 Closure
9 Transfer
Reason for transfer ...................................................................... Status of functioning ...................................................................
Reason to end treatment ............................................................. Date of sending a report to referring physician ..........................
Results achieved ..........................................................................
Date of session ............................................................................ Therapeutic/preventive procedures given ....................................
Treatment goals ........................................................................... Planned therapeutic/preventive procedures ................................. Planned amount of sessions/planned treatment period ...............
Diagnosis formulated .................................................................. Indication for care given (yes/no) ...............................................
Diagnostic procedures ................................................................. Diagnostic aids ............................................................................ Findings of professional ..............................................................
Reason of encounter .................................................................... Medical history ............................................................................ Complaints/findings of patients ................................................... Social-economic data (education, housing) ................................. Technical aids used by patients ...................................................
Referral date ................................................................................ General data (name, address, gender) ......................................... Referring physician ...................................................................... Referring diagnosis ......................................................................
– ICIDH/ICF
– –
ICIDH/ICF/NOC
– ICNP/NIC
ICIDH/ICF ICNP/NIC –
ICIDH/ICF/ICD/DSM/NANDA/ICNP –
– – ICIDH/ICF
– ICD/DSM/ICPC ICIDH/ICF – –
– – – ICD/DSM/ICPC
Classifications used by nurses
– –
ICIDH/ICF
– Draft classification of procedures
ICIDH/ICF Draft classification of procedures –
ICIDH/ICF (for some of the elements) –
Draft classification of procedures Adaptation of ISO 9999 ICIDH/ICF
– (selection from) ICD/ICPC ICIDH/ICF – Adaptation of ISO 9999
– – – (selection from) ICD/ICPC
Classifications used by allied health professionals
(DSM = Diagnostic and Statistical Manual to the mental disorders; ICD = International Classification of Diseases;13 ICNP = International Classification of Nursing Practice;14 ICPC = International Classification of Primary Care;15 NANDA = North American Nursing Diagnosis Association; NIC = Nursing Interventions Classification;16 NOC = Nursing Outcomes Classification17)
Ô
1 Referral
Important data
Table 2 Overview of the process of care (first column), the relevant data (second column) and the classifications used to describe these data in nursing (third column) and allied health professions (fourth column)
Y. Heerkens et al.
Past and future of the ICF –
–
a manual registration system for patients with a burned hand. In this system for physical therapy, five assessment instruments are incorporated to evaluate functioning (defined in ICIDH-terms); a manual registration system for occupational therapists, speech therapists and physical therapists working with persons with a mental handicap.19
–
– .
clinical practice, e.g. – use of diagnostic terms in nursing practice (1995 – 1998). Based on ICIDH-versions (including the CDV) several sets of diagnostic terms have been composed in psychiatric care,20 general care21 and AIDS-care.22 In such a set the label and problem definition, related factors and
–
the signs and symptoms of a health problem, like pain, anxiety or limitation in dressing activities, are elaborated; exploration of the match between the Beta-2 draft and the nursing domain. The results of two pilot studies23 indicate that the the Beta-2 draft is relevant to the nursing discipline and allows a large majority of nursing diagnoses to be classified; exploration of the usefulness of the Beta2 draft for nursing care. This is a joint project of three university hospitals, the University of Nijmegen and the Dutch Center for Nursing and Nursing Assistants (LCVV). In figure 1 a description of the projects in the three hospitals is given; development of a system for eligibility for defined physical therapy and exercise
Projects of the University Hospital Groningen The University Hospital Groningen has developed instruments for: (1) patients with a chronic neurological disorder who undergo intra- and extra-mural multidisciplinary care; (2) screening the state of health by stroke patients in the acute phase at Central Emergency Unit; (3) the transition of the apoplexy patient from the hospital to the nursing home or revalidation clinic; (4) geriatric patients at the Day-Treatment Centre, where diagnostics take place and treatment advice formulated. Projects of the Academic Medical Centre, Amsterdam The structure, terminology and qualifiers of the ICIDH are used and evaluated in the following four projects: (1) Development of standard nursing care plans: three nursing care plans (problem definition, goals and interventions) for the health problems pain, disorientation and non-compliance are developed. (2) Development of global assessment tools and structured patient reviews: two different nursing assessment tools are developed, one for the Internal Division and one for the Psychiatric Division. The latter will be a digital version. The same structure is used during the patient reviews. (3) Development of a multidisciplinary patient record system for palliative gynaecological patients. (4) Construction of a clinical pathway for patients who undergo lung surgery. Projects of the St. Radboud University Medical Centre, Nijmegen (1) Study on the practical possibility of converting existing nursing diagnoses into Beta-2 draft terms. Three different sources of diagnoses are included in the project: (a) An existing nursing diagnoses data base, (b) Data on patients who are under care, and (c) Data from existing standard care plans.39 (2) Study on the usefulness of the Beta-2 draft for the collection of patient data that are relevant in nursing care, and for the formulation of nursing diagnoses. This study will include both a process and an effect evaluation with a pre and a post measurement on quality and quantity of data collection and formulation of the diagnoses. Figure 1 Projects in the study ‘Application of the ICIDH-2 in Nursing (2000 – 2002)’.37,38
623
Y. Heerkens et al. therapy services. The goals of the services are formulated in ICIDH-terminology.5
.
professional guidelines: in the last 5 years there has been an emphasis on the development of – ‘evidence based’ – guidelines for allied health professionals. In these guidelines terms of the ICIDH are used to describe aspects of the diagnostic and therapeutic process (such as complaints, findings, goals, results). For several allied health professions guidelines have been made. Some examples are: – for physical therapy and exercise therapy: patients with genuine stress incontinence,24 chronic obstructive pulmonary disease,25 low back pain, whiplash, and osteoporosis; – for occupational therapy: diagnostics and treatment in patients with amyotrophic lateral sclerosis, and diagnostics directed to sitting in children with cerebral palsy; – for speech therapy and dietetics: diagnostics and treatment of problems with swallowing in nursing homes patients.26
Recently more emphasis is put on multidisciplinary guidelines, in which the use of the ICIDH-terms is even more relevant to facilitate communication between professions.
–
–
clinical trials, e.g.: –
–
reliability studies, e.g. the interobserver reliability of a registration form for exercise therapy that draws on the conceptual framework of the ICIDH was tested.27 The reliability (based on percentage of agreement and Cohen’s Kappa) proved to be satisfactory; the intraobserver and interobserver reliability of assessments of impairments and disabilities in physical therapy has been studied some years ago.28 The interobserver agreement was much less than the intraobserver agreement.
–
624
description of the patient population of allied health professions using the ICIDH-terminology; such as chiropodists,29 exercise therapists,30 dieticians, occupational therapists and physical therapists;
analysis of the ICIDH-model for use as a framework for selection, improvement and development of outcome instruments (e.g. 32, 33); classification of assessment instruments relevant for patients with rheumatoid arthritis. The ICIDH was used to classify the goal of the assessment instruments as formulated by the authors.
teaching material, e.g.: –
epidemiological research and patient profiles, e.g.: –
comparing the outcomes of a group of patients treated by physical therapists and another group receiving the normal care of general practitioners. The health profile of the patients is described using terms from the Beta-2 draft. For the physical therapists four treatment protocols are available. Which protocol to follow is dependent on the pain and the limitations in activities experienced by the patient.31
clinimetrics, e.g.: –
– –
comparing low back patients treated by manual therapists with patients receiving ‘normal’ physical therapy. Patients treated by manual therapists appeared to have personal factors (like age and profession) and problems in functioning (described in ICIDH-terms) that are different from those in patients treated by physical therapists; description of the patient population of children’s physical therapists. In this ongoing study the ICF is used to document the problems in functioning, including behavioural problems, ‘social’ external factors (e.g. the way of handling the child by parents and teachers), and other external factors (such as the child’s home, neighbourhood, school and sport environment).
–
production of a videotape ‘Diagnostic reasoning in nursing’. In this videotape an explanation is given of how diagnostic activities can be supported by using the Gordons’ FHP.4 The possibility of using the concepts and terms contained in the ICIDH within this framework is also introduced in this videotape;34 development of educational programmes based on casuistry from every day nursing practice (e.g. 35 ). Teacher’s manuals are available;
Past and future of the ICF –
development of teaching material, including ICIDH-terminology, to introduce ‘uniformity of language’ into the curricula of seven allied health professions.36
.
other uses, e.g.: – –
–
inclusion of ICIDH-terms in a list of keywords for the selection of literature; development of a new professional profile for nursing and for several allied health professions. ICIDH-terminology is used to describe the relevant patient populations; distinction of several professional levels in nursing care.
SYSTEMATIC DESCRIPTION OF (POSSIBLE) USE OF THE
.
can be used for instance in the description of professional profiles; use of the terminology within the classification without using the codes: The use of terms from the classification – without actually coding – is the most important level at this moment and is often used in both spoken and written communication when there is no need to aggregate data. Examples are the development of multidisciplinary guidelines, the selection of assessment instruments, and the development of assessment instruments; use of the codes: The use of codes is relevant in all those cases that aggregation of data is relevant, such as in (electronic) registration systems, reimbursement, and research.
ICIDH/ICF
It is important to describe in which situations use of ICIDH/ICF terminology and the codes is useful, but also in which situations use of the ICIDH/ICF terminology and codes is superfluous and even hampering. In communication on micro level (individual care), spoken language is most appropriate to discuss the situation of the patient. While talking with or about an individual patient with other care-givers and the referring physician one does not need specific terms from a classification. Also in written communication free text, based on natural language, can be very informative. However in both situations the use of the basic terms of the framework of the ICF may structure and clarify the communication: the problems of the patient are described on three levels, and negative and positive external and personal factors are indicated. When information is generated about different patients and when data of individual patients are used to generate general information on meso- and macro level (aggregation of data), classifying and coding of data is necessary. Comparing the results of different therapists or different departments (mirror information) and research require ‘numeric’ data – data that can be added, compared and transformed. Consequently there are different levels of applying the ICF: .
use of the basic terms and their mutual relationships: the basic framework of the ICF The basic terminology of the ICIDH can be used adequately when it is necessary, e.g. to position a certain profession. In this way the terminology
PROBLEMS IN USING THE ICIDH
As indicated in the introduction the terminology offered by the ICIDH is very useful for nursing and allied health professions. However, actual use of the ICIDH is not easy and often results in discussion on the definition of the terms, the borders between functions and activities and between activities and participation, the lack of terms for specific purposes and the level of detail needed. For several applications, the ICIDH itself – and also the new ICF – is too general to be used in describing functioning of patients on a level of detail needed for nurses and allied health professionals. For example, when it is known that a patient has a problem in a5101 ‘washing whole body’, this information is not detailed enough for an occupational therapist or a nurse. The occupational therapist or nurse needs to know whether the problem is the handling of soap, the application of water, reaching all parts that need to be cleaned, or knowing the right order of actions involved. NEED OF AN ADAPTED VERSION OF ICF
The most important, and urgent, consequence of the introduction of the ICF is the perceived need and necessity to develop a more detailed version of the ICF to describe problems in functioning on micro level. There is general agreement that it is better to make one adaptation including the specific terms for all professions involved, a so called Clinical Modification, instead of separate versions, e.g. one for speech therapy, one for dieticians, one for nurses. It would not make sense to use different terms for the same phenomenon. In the 625
Y. Heerkens et al. development of this modification other professions, like welfare officers, psychologists, physicians and other professions using the ICIDH/ICF should be involved to promote uniformity of language. For specific purposes, e.g. for certain groups of patients, it is possible to derive from this comprehensive adaptation, differently specialized, but compatible versions. Subsequent activities In the past the ICIDH has been introduced into the curricula of many health care professions. In primary education of allied health professionals the terminology of the ICIDH is often used. This implicates that – with the publication of the ICF – all teachers must be informed and trained in the use of the ICF, and that all training materials must be adapted to the new scheme introduced, the new terms, the new definitions and to all other changes made. The same is true for the terms derived from the ICIDH used in the description of professional profiles, in guidelines and in all other applications of the ICIDH. This will definitely take some time, probably several years. Introduction of the ICF in initial education is of course important, but there are still many professionals (especially those who have received their education more than 10 years ago) who are not acquainted with the ICIDH/ICF. Plans must be made to implement the ICF (and the ICF-CM) within the nursing and allied health professions as a whole, e.g. by postgraduate education. It also needs to be considered what the consequences would be for educational and professional principles and policies based on the framework of the former ICIDH. Researchers, policy makers and other health professionals must learn to use the new terminology as well. It can be foreseen that new developments in health care, like managed care and shared care or seamless care, will stimulate medical specialists and general practitioners to use ICF-terminology next to the ICD or the ICPC. One thing is clear; it will be a major effort and challenge to introduce the new Dutch ICF40 to 350 000 nurses and nursing attendants, 35 000 allied health professionals and all other professionals using the former ICIDH in the Netherlands and to all future users of the ICF. References 1 WHO. International Classification of Impairments, Disabilities and Handicaps; A manual of classification relating to the consequences of disease. Geneva: World Health Organization 1980/1993.
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2 Ten Napel H. Classificatie van Diagnostische Termen voor de Verpleegkunde (CDV), [Classification of Diagnostic Terms for nursing (CDV)] Zoetermeer: Nationale Raad voor de Volksgezondheid/WCC 1996. 3 WCC. Backgroundpaper. Proposal for adaptation of the classification of impairments and the classification of disabilities of the ICIDH from the perspective of five Dutch allied health professions. Zoetermeer: Dutch Classification and Terminology Committee for Health/Dutch WHO Collaborating Centre for the ICIDH 1993. 4 Gordon M. Nursing Diagnosis: Process and Application St Louis: Mosby 1994. 5 Halbertsma J, Heerkens Y, Hirs W, de Kleijn-de Vrankrijker M, Van Ravensberg D, Ten Napel H. Comments on the ICIDH-2 Beta-2 draft and the results of field trials. Bilthoven: RIVM report 2000. 6 Frederiks CMA. The usefulness of the ICIDH in classifying nursing problems. In: Oud, N (ed), Proceedings of the third European Conference of the Association of Common European Nursing Diagnosis, Interventions and Outcomes in Berlin Bern: Verlag Hans Huber 2001; 220 – 221. 7 van Ravensberg CD, Heerkens YF, Brandsma JW. Bewerking van de ICIDH, stoornissen/functies en beperkingen/vaardigheden, [Adaptation of the ICIDH: impairments/functions and disabilities/ activities] Amersfoort: Nederlands Paramedisch Instituut juli 1995. 8 WCC. Revision of the ICIDH, propositions from speech and language therapy. Zoetermeer: Nationale Raad voor de Volksgezondheid, Dutch Classification and Terminology Committee for Health 1994. 9 Heerkens YF, Spijker MC, Klein A, van Ravensberg CD. Ontwerpclassificatie Gezondheidstoestand voor de Logopedie (Ontwerp ICIDH-logopedie), [Draft classification of health status for speech therapy (Draft ICIDH-speech therapy)] Amersfoort: Nederlands Paramedisch Instituut/Npi mei 1998. 10 Beens MC, Heerkens YF. Ontwerpclassificaties en codelijsten voor de die¨tetiek, [Draft classifications and coding lists for dieticians] Oss/Amersfoort: Nederlandse Vereniging van Die¨tisten/Nederlands Paramedisch Instituut/Npi januari 1999. 11 Corbey-Verheggen MJH, Heerkens YF. Ontwerpclassificaties en codelijsten voor Mondhygie¨ne, [Draft classifications and coding lists for oral hygiene] Bunnik/Amersfoort: Nederlandse Vereniging van Mondhygie¨nisten/Nederlands Paramedisch Instituut maart 1999. 12 World Health Organisation. International Classification of Functioning, Disability and Health. World Health Organization, 2001. 13 World Health Organisation. International Statistical Classification of Diseases and Health related Problems; Tenth revision. Geneva: World Health Organization 1992. 14 ICNP. http://www.icn.ch/icnpupdate.htm. 15 Gebel RS, Okkes IM (eds). ICPC-2-NL, International Classification of Primary Care. Tweede editie, Nederlandse versie. Utrecht: Nederlands Huisartsen Genootschap & Amsterdam: AMC 2000. 16 Bulecheck GM, McCloskey JC (eds). Nursing Intervention Classification (NIC) (3rd edition) St. Louis: Mosby 2000. 17 Johnson M, Maas M, Moorhead S (eds). Nursing Outcome Classification (NOC) (2nd edition) St. Louis: Mosby-Year Book 2000. 18 Graetz PAM, Timmermans H, Broekhuizen AC. Eindrapport Project Logopedie Informatie Systeem, [Final report of the project Information System for Speech Therapy] Utrecht: Centraal Begeleidingsorgaan voor de Intercollegiale Toetsing/CBO 1995. 19 Heerkens YF, van den Berg P, Scholte F. Occupational therapy, speech therapy and physical therapy for persons with a mental handicap 1st World Congress of the International Society of Physical and Rehabilitation Medicine; Abstract book, Amsterdam, 7 – 13 July 2001.
Past and future of the ICF 20 Boomsma J, Dingemans C, Dassen T, van den Heuvel W. Verpleegkundige methodiekontwikkeling ten behoeve van de psychiatrische thuiszorg (evaluatierapport), [Development of nursing methods for psychiatric home care (evaluation report)] Groningen: Noordelijk Centrum voor Gezondheidsvraagstukken/ Universiteit van Groningen 1997. 21 van der Brug YM, Tjepkema J. ICIDH in de verpleegkunde: Sets Diagnostische Termen, [ICIDH in nursing: sets of diagnostic terms] Amsterdam: Academisch Medisch Centrum, Universiteit van Amsterdam 1998. 22 Zelm van R, Kolk N, ten Napel H. Verpleegkundige zorg voor patie¨nten met HIV/AIDS: gegevenssets, [Nursing care for patients with HIV/AIDS: datasets] Utrecht: NIZW 1997. 23 van Achterberg T, Frederiks C, Thien N, Coenen C, Persoon A. Using ICIDH-2 in the classification of nursing diagnoses: results from two pilot studies. Accepted for publication, Journal of Advanced Nursing (in press). 24 Berghmans LCM, Bernards ATM, Hendriks HJM, Bø K, Grupping MHM. Guidelines for the physiotherapeutic management of genuine stress incontinence, Physical Therapy Review 1998; 3(3): 133 – 147. 25 Bekkering GE, Hendriks HJM, Paterson WJ, et al. Guidelines for physiotherapeutic management in chronic obstructive pulmonary disease, Physical Therapy Review 2000; 5(1): 59 – 74. 26 Bogaardt HCA, Franchimont H, van Ravensberg CD. Slikproblemen bij verpleeghuisbewoners: multidisciplinaire informatie en richtlijnen die¨tetiek, logopedie en verpleeghuisartsen, [Problems with swallowing: multidisciplinary information and guidelines for dieticians, speech therapists and nursing home doctors] 2000. 27 Gisbergen MJWM, Dekker J. Reliability of the diagnosis of impairments and disabilities by exercise therapists, Journal of Rehalibilitation Sciences 1992; 5(2): 67 – 73. 28 Hendriks EJM, Brandsma JW, Heerkens YF, Oostendorp RAB, Nelson RM. Intraobserver and interobserver reliability of assessments of impairments and disabilities, Physical Therapy 1997; 77: 1097 – 1106. 29 Zuijderduin WM, Dekker J. Diagnoses and interventions in podiatry, Disability and Rehabilitation 1996; 18(1): 27 – 34. 30 Zuijderduin WM, Dekker J. Oefentherapie-Cesar en oefentherapieMensendieck in de Nederlandse gezondheidszorg, [Exercise therapy according to Mensendieck and according to Cesar in Dutch Health care] Utrecht: Nederland instituut voor onderzoek van de eerstelijnsgezondheidszorg/Nivel 1994.
31 Peeters GGM, van de Steen CWM, Bernards ATM, de Visser AC. Gezondheidsprofiel van de ‘whiplash’ patie¨nt als uitgangspunt voor behandeling: bruikbaar in de huisartspraktijk? [Health profile of the ‘whiplash’ patient as starting point for treatment: applicable for the primary physician?] Modern Medicine 2000; 12: 1076 – 1084. 32 de Haan R, Horn J, Limburg M, Van der Meulen J, Bossuyt P. A comparison of five stroke scales with measures of disability, handicap, and quality of life, Stroke 1993; 24: 1178 – 1181. 33 de Haan R, Limburg M. Relation between impairment and functional health scales in the outcome of stroke Cerebrovasc Dis 1994; 4(suppl 2): S19 – S23. 34 van der Brug YM, van Mourik F. ‘Diagnostic reasoning in Nursing’ (Video). Vernieuwingsproject Methodiekontwikkeling in het Verpleegkundig Onderwijs, Hanzehogeschool, Hogeschool van Groningen 1996. 35 van der Brug Y. Leerroutes naar gebruik van de ICIDH: werkboek gericht op toepassingen van de ICIDH in het primair proces (en docentenhandleiding), [Routes of learning in using the ICIDH: exercise book directed on application of the ICIDH in the primary process (and manual for teachers)] Amsterdam: Academisch Medisch Centrum, Universiteit van Amsterdam 1998. 36 Heerkens YF. Eenheid van taal. Zorg op Maat, [Uniformity of language. Tailored care] Groningen: Hanzehogeschool, Hogeschool van Rotterdam, Nederlands Paramedisch Instituut, Fontys Hogeschool 2001. 37 van der Brug YM, Frederiks C, Heijnen-Kaales Y, Hellema F, Roodbol G. De ICIDH en de verpleegkunde. Een geschikt systeem voor multidisciplinaire samenwerking, [The ICIDH and nursing. A suitable system for multidisciplinary cooperation] TVZ, Tijdschrift voor verpleegkundigen 2001; (9): 275 – 278. 38 Oud N. Proceedings of the third European Conference of the Association of Common European Nursing Diagnosis, Interventions and Outcomes, Berlin 2001. 39 Heinen M, van Achterberg T, Roodbol G. Theoretische mogelijkheden van de ICIDH, deelproject 1, [Theoretical possibilities of the ICIDH, subproject 1] Nijmegen: Staf zorg UMC St Radboud 2001. 40 RIVM. ICF. Dutch translation of the International Classification of Functioning, Disability and Health. Bilthoven: Dutch WHO FIC Collaborating Centre 2002.
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