Spinal Cord (2018) 56:322–331 https://doi.org/10.1038/s41393-017-0039-x ARTICLE Administration of assessment instruments during the first rehabilitation of patients with spinal cord injury: a retrospective chart analysis Patricia Lampart 1,2 ● Armin Gemperli 2,3 ● Michael Baumberger 1 ● Ines Bersch 1 ● Birgit Prodinger 2,3 ● Klaus Schmitt 1 ● Anke Scheel-Sailer 1,2 Received: 23 June 2017 / Revised: 26 October 2017 / Accepted: 12 November 2017 / Published online: 20 December 2017 © International Spinal Cord Society 2017 Abstract Study design Retrospective chart analysis. Objectives To examine which professionals administered which assessment instruments in which patient in clinical practice during first rehabilitation after newly acquired spinal cord injury (SCI) and the differences in the frequencies of different assessments between patient groups. Setting Specialized SCI acute care and rehabilitation clinic. Methods Patients after SCI, aged 18 years and above, admitted for first rehabilitation between December 2014 and December 2015 were analyzed. Descriptive statistics of 54 selected assessments. p values based on the χ 2 test were calculated for assessments used in both paraplegic and tetraplegic patients. Results One hundred and nineteen patients were screened. Forty-one assessments were administered, of which 10 on average more than once per patient. The most frequently used assessments were Spinal Cord Independence Measure III (7.7 times per patient), Skin Assessment (3.6 times), and Manual Muscle Test (3.2 times for Lower Extremities; 2.5 times for Upper Extremities). The American Spinal Injury Association Impairment Scale was administered on average 1.9 times per patient. More variation in the number of assessments per patient was observed in patients with complete and incomplete lesions compared to patients with paraplegia and tetraplegia. Conclusion Assessments covering neurological functioning, mobility, and self-care are used in clinical practice during first rehabilitation of patients with SCI, while others covering autonomic functioning, pain, participation, or quality of life are still missing. Based on these observations and national and international requirements, a meaningful standard for an assessment toolkit, applicable in general and in specific subgroups, needs to be defined and implemented. Introduction Assessments are an essential part of rehabilitation man- agement at a micro-level. However, they are also embedded in a wider framework that comprises quality management programs at the meso-level and national reporting at the macro-level [1–3]. National reporting requires harmonized data collection according to a widely accepted framework that includes, for example, internationally accepted classi- fications such as the International Classification of Diseases (ICD) or the International Classification of Functioning, Disability, and Health (ICF) [4–6]. These classifications can be considered to make up a unifying model that determines “what to measure” [6–8]. The living conditions and functional capacity of a per- son affected by a spinal cord injury (SCI) depend on the level of body structure and function, activity, and partici- pation, as well as personal and contextual factors [9]. In order to examine these components in a comparable and defined way, certain assessments are used as part of * Anke Scheel-Sailer anke.scheel@paraplegie.ch 1 Swiss Paraplegic Centre (SPC), Nottwil, Switzerland 2 Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland 3 Swiss Paraplegic Research (SPF), Nottwil, Switzerland Electronic supplementary material The online version of this article (https://doi.org/10.1038/s41393-017-0039-x) contains supplementary material, which is available to authorized users. 1234567890