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

Abstract Background Accurate and standardized documentation is essential for high-quality physiotherapy practice, yet deficiencies in shoulder rehabilitation documentation remain prevalent. This study aimed to evaluate the comprehensiveness and quality of documentation pertaining to shoulder rehabilitation, develop a standardized shoulder-specific physiotherapy documentation tool, and evaluate its psychometric properties. Methods A two-phase observational study was conducted at the Department of Physical Therapy, Riphah Rehabilitation Center, Lahore, Pakistan. Phase I comprised a retrospective clinical audit of 333 eligible shoulder rehabilitation records selected from 1,000 screened records to assess the completeness and quality of routine documentation. Phase II involved the development and psychometric evaluation of a shoulder-specific physiotherapy documentation tool, including assessment of content validity, construct validity, internal consistency, test–retest reliability, inter-rater reliability, and preliminary usability among physiotherapists. Principal Component Analysis (PCA), Cronbach’s alpha, and intraclass correlation coefficients (ICC) were used to evaluate the psychometric properties of the developed tool. Results The clinical audit identified substantial deficiencies in routine shoulder rehabilitation documentation, particularly in cervical screening (42.6%), non-standardized range-of-motion recording (36.3%), treatment planning (34.5%), and subjective history (23.4%). The developed documentation tool demonstrated excellent content validity (S-CVI = 1.00), acceptable sampling adequacy (KMO = 0.671), and a significant Bartlett’s test of sphericity (χ² = 133.747, df = 36, p < 0.001), acceptable internal consistency (Cronbach’s α = 0.70), strong test–retest reliability (ICC = 0.89), and strong inter-rater reliability (ICC = 0.87), Preliminary usability assessment among 20 physiotherapists yielded a mean System Usability Scale (SUS) score of 95.5 ± 2.1, indicating excellent perceived usability. Conclusion The study identified important deficiencies in shoulder rehabilitation documentation and developed a standardized shoulder-specific physiotherapy documentation tool with preliminary evidence regarding its validity, reliability, and usability. The proposed tool may provide a structured framework for shoulder rehabilitation documentation. Further prospective multicentre implementation studies are required to determine whether routine use of the tool improves documentation quality and clinical practice.