Audit Finds Gaps in Shoulder Rehabilitation Records, Prompting a New Documentation Tool

Physiotherapists at a rehabilitation centre in Lahore, Pakistan, frequently failed to record key components of shoulder assessment in their routine clinical notes, according to a retrospective audit of 333 shoulder rehabilitation records. The most common gap was the absence of cervical screening documentation, which was missing from 142 records, or 42.6 percent of the audited sample. Non-standardized recording of range of motion appeared in 121 records (36.3 percent), incomplete treatment planning in 115 records (34.5 percent), and incomplete subjective history in 78 records (23.4 percent). The audit, published in the Bulletin of Faculty of Physical Therapy, formed the first phase of a two-phase observational study conducted at the Department of Physical Therapy, Riphah Rehabilitation Center, between November 2024 and March 2025.

The second phase of the study used these audit findings to develop a standardized Shoulder-Specific Physiotherapy Documentation Tool, which was then subjected to a battery of psychometric tests. The tool achieved a scale-level content validity index of 1.00, an acceptable internal consistency with a Cronbach’s alpha of 0.70, strong test-retest reliability with an intraclass correlation coefficient of 0.89, and strong inter-rater reliability with an ICC of 0.87. In a preliminary usability assessment, 20 physiotherapists gave the tool a mean System Usability Scale score of 95.5 with a standard deviation of 2.1, with individual scores ranging from 90.0 to 97.5, indicating excellent perceived usability within that sample. The authors stress that these are preliminary findings from a single institution and that further prospective multicentre implementation studies are required before any conclusions can be drawn about whether routine use of the tool improves documentation quality or clinical practice.

Shoulder disorders are among the most prevalent musculoskeletal conditions encountered in clinical practice and are a major cause of pain, disability, reduced functional capacity and diminished quality of life. They encompass a wide range of conditions, including rotator cuff-related shoulder disorders, adhesive capsulitis, glenohumeral instability, osteoarthritis and traumatic injuries, all of which can substantially impair upper-limb function and participation in activities of daily living. Physiotherapy plays a central role in both conservative and postoperative shoulder rehabilitation through comprehensive assessment, therapeutic exercise, manual therapy, patient education and progressive functional rehabilitation. Accurate assessment and systematic documentation are therefore essential to support clinical reasoning, guide treatment planning, ensure continuity of care, facilitate interdisciplinary communication and evaluate rehabilitation outcomes.

The research team argues that clinical documentation is a fundamental component of high-quality physiotherapy practice. Comprehensive documentation enhances communication among healthcare professionals, supports evidence-based clinical decision-making, improves patient safety, provides medico-legal protection, and facilitates clinical audit, quality improvement, education and research. The study also draws on the International Classification of Functioning, Disability and Health, a framework that integrates impairments, activity limitations, participation restrictions, environmental factors and personal factors into rehabilitation practice. However, the authors note that established shoulder outcome measures such as the Shoulder Pain and Disability Index, the Disabilities of the Arm, Shoulder and Hand questionnaire, the QuickDASH, the American Shoulder and Elbow Surgeons score and the Constant-Murley Score, despite their robust psychometric properties, are designed primarily to measure patient- or clinician-reported outcomes rather than to organize the clinical information required for routine physiotherapy documentation.

For the audit phase, the researchers screened 1,000 outpatient physiotherapy records sequentially against predefined eligibility criteria. Records were eligible if they involved patients aged 18 years or older with a diagnosis of a rotator cuff disorder, adhesive capsulitis or shoulder impingement syndrome and had a shoulder rehabilitation record available during the study period. Records were excluded if they involved neurological, systemic or multi-joint musculoskeletal disorders affecting upper-limb function, were duplicates, or were illegible and could not be reliably reviewed. A total of 333 records met the criteria and were included, and all eligible records identified during the predefined study period were audited, which meant that no separate a priori sample-size calculation was performed for this phase. Records were included irrespective of the completeness or quality of their documentation, a deliberate choice to avoid selecting records on the basis of the outcome being audited.

The audited records showed a broadly even distribution of shoulder diagnoses. Rotator cuff disorder was the most frequently documented primary diagnosis, appearing in 145 records (43.5 percent), followed by adhesive capsulitis in 98 records (29.4 percent) and shoulder impingement syndrome in 90 records (27.1 percent). Of the included records, 198 (59.5 percent) were from male patients and 135 (40.5 percent) were from female patients, with a mean age of 42.75 years and a standard deviation of 12.34 years, and an age range of 18 to 65 years. The audit evaluated documentation practices rather than patient clinical outcomes, and the authors explicitly state that no patient outcome analysis or correlation analysis between documentation completeness and patient clinical outcomes was performed. The audited components included participant age, pain severity at rest, duration of symptoms, cervical rotation, shoulder flexion strength, shoulder extension strength, motor function deficits and treatment frequency.

At the study setting, physiotherapists had routinely used a general musculoskeletal assessment form for patients with different musculoskeletal conditions rather than a shoulder-specific template. Although suitable for general clinical documentation, the existing form did not provide a structured framework for recording important shoulder-specific assessment findings such as cervical screening, standardized range of motion, strength assessment and treatment planning. The documentation tool was developed using four sources: the findings of the retrospective clinical audit, published literature, the ICF framework and expert consensus. A preliminary version was refined through a two-round modified Delphi process involving four experienced musculoskeletal and orthopedic physiotherapists with 15 to 20 years of clinical experience. The final tool comprises nine sections: Subjective Assessment, Pain Assessment, Cervical Screening, ROM and Joint Play, Muscle Strength, Motor Function and Neurological Screening, Special Tests, Treatment Plan, and Treatment Frequency and Follow-up.

The psychometric evaluation of the tool involved several complementary analyses. Content validity was assessed through the Delphi process, in which all nine documentation sections received a rating of 4 from all four experts, yielding an item-level content validity index of 1.00 for every section and a scale-level content validity index of 1.00, indicating complete agreement among the expert panel regarding the relevance of the included sections. Construct validity was explored using exploratory factor analysis through Principal Component Analysis. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.671 and Bartlett’s test of sphericity was statistically significant, with a chi-square value of 133.747, 36 degrees of freedom and a p value below 0.001, indicating that the dataset was suitable for component analysis. Extracted communalities ranged from 0.341 to 0.979, indicating variation in the proportion of variance represented by the retained components.

The PCA identified two components with eigenvalues greater than 1.0. Component 1 had an eigenvalue of 3.954 and explained 43.93 percent of the total variance, while Component 2 had an eigenvalue of 2.241 and explained 24.90 percent; together the two components accounted for 68.83 percent of the total variance. Following Varimax rotation, Component 1 was characterized primarily by Motor Function and Neurological Screening and Special Tests, each with a loading of 0.923, with additional contributions from Treatment Frequency and Follow-up (0.596), Pain Assessment (negative 0.582), Subjective Assessment (negative 0.536) and Cervical Screening (negative 0.645). Component 2 was characterized primarily by ROM and Joint Play (0.987), Muscle Strength (0.987) and Treatment Plan (0.926). The authors interpret these patterns as two broadly distinguishable domains within the documentation sections, with the first component reflecting neurological, special-test, symptom- and screening-related documentation and the second reflecting physical examination and treatment-planning domains. Because the PCA was exploratory and the tool is newly developed, the authors caution that this structure should be regarded as preliminary and confirmed in future studies using independent samples and confirmatory analyses.

Reliability testing used the same 333 eligible records from the audit phase, which were evaluated with the developed tool at two assessment points separated by a 10-day interval, yielding a test-retest ICC of 0.89. Inter-rater reliability was assessed among 20 physiotherapists at the centre with 5 to 7 years of clinical experience, who independently applied the tool; both analyses used a two-way mixed-effects ICC model with absolute agreement, and the inter-rater ICC was 0.87. The same 20 physiotherapists, recruited by convenience sampling based on availability and willingness to participate, completed the 10-item System Usability Scale, in which each item is scored on a five-point Likert scale and higher scores indicate greater perceived usability. Cronbach’s alpha for the SUS responses was 0.983. The authors emphasize that the usability assessment involved a small convenience sample from a single institution and measured perceived usability rather than actual improvements in documentation completeness, efficiency, clinical decision-making or patient outcomes.

The study’s limitations are set out explicitly by the authors. The research was conducted at a single rehabilitation centre, which may limit generalizability to other physiotherapy settings. The Phase II evaluation used convenience sampling of 20 physiotherapists from the study setting, which may introduce selection bias, and the Delphi panel consisted of only four experts, which may limit the breadth of expert representation. The study also did not include a control or comparison group using an established standardized documentation system. Importantly, the authors state that the findings should not be interpreted as evidence that use of the tool improves patient outcomes or clinical effectiveness, since no correlation analysis between documentation completeness and clinical outcomes was performed. They position the proposed tool as a structured framework that may help clinicians consistently record selected clinically relevant assessment information, and as complementary to established shoulder outcome measures rather than a replacement for them. Prospective multicentre studies are required to determine the feasibility and effectiveness of implementing the tool in routine clinical practice, and to establish whether routine use improves documentation quality, clinical decision-making, continuity of care or patient outcomes.

Subject of Research: A clinical audit of shoulder rehabilitation documentation and the development and psychometric validation of a standardized shoulder-specific physiotherapy documentation tool

Article Title: Assessment of shoulder rehabilitation practices and development of a standardized physiotherapy documentation tool: a retrospective clinical audit and psychometric validation study

Article References: Tariq, M., Hashim, M., Hassan, D., Butt, A., Haroon, M., & Aslam, J. (2026). Assessment of shoulder rehabilitation practices and development of a standardized physiotherapy documentation tool: a retrospective clinical audit and psychometric validation study. Bulletin of Faculty of Physical Therapy, 31(1), Article 40. https://doi.org/10.1186/s43161-026-00376-5

Image Credits: AI Generated

DOI: 10.1186/s43161-026-00376-5

Keywords: physiotherapy, shoulder rehabilitation, clinical documentation, clinical audit, psychometric validation, reliability, content validity, System Usability Scale, rotator cuff disorder, adhesive capsulitis, rehabilitation records, Pakistan