Introduced to the Committee by Bent Guttorm Bentsen in 1988 under the basis of the work of the Dartmouth CO-OP project, the Functional Status Assessment Charts have been adapted and edited under the name of

The COOP/WONCA charts

In 1987 the WONCA Classification Committee began to develop a way of classifying and recording the overall functional status of the patient as distinct from the status of severity of their health problem(s) Over a number of years this work, later conducted in co-operation with the WONCA Research Committee, resulted in production of the COOP/WONCA Functional Status Assessment Charts.

Functional status is a measure of an individual's overall well-being. It is one of the set of global measures of health status, which also include assessments of clinical status and quality of life. The International Glossary for general/family practice defines functional status as "the ability of a person to perform and adapt to his/her environment, measured both objectively and subjectively over a stated period of time". Implicit in any definition of functional status is the importance of factors other than disease in the health of patients. As the complexity and chronicity of medical problems increase, community medical practitioners will become more reliant on indicators of functioning as well as disease status to monitor their interventions and measure health outcomes.

Functional status relates to the patient, not to the health problem, disease or episode of care. It thus relates less directly to the ICPC codes than does severity of illness. However its importance in general/family practice warrants its inclusion in this book.

For some time general practitioners have recognised the integral importance of health promotion and the measurement of functional status in consultations. These measurements are particularly important in dealing with ageing and those with chronic problems. The addition of functional status measures to the recording of reason for encounter, diagnosis and therapeutic interventions is a logical step for the process of classification in general/family practice.

Instruments for measuring functional status

One of the first instruments to be recognised by WONCA as a reliable and practical measure of functional status in the family practice setting was the Dartmouth COOP Functional Assessment Charts. These charts were modified by the classification committee and promoted for use in conjunction with ICPC. The revised charts are known as the COOP/WONCA charts.

The COOP/WONCA charts, whilst specifically developed for general/family practice are not the only instruments available for assessing functional status. There are a plethora of indicators currently available. Several have been used in general practice settings. The Medical Outcomes Trust Short Form 36 item inventory and derivatives of this instrument have been widely used in primary care settings. Similarly, the Duke Health Profile has been used successfully in North American settings In Europe, several other instruments have been used. The Sickness Impact Profile (SIP) and the Nottingham Health profile are the two most widely cited. Some of these instruments were designed for research not clinical purposes, for example, the Sickness Impact Profile.

To date, the COOP/WONCA charts have been tested most extensively in general/family practice settings. Internationally, they have been found to have good face validity and clinical utility in general practice. General practitioners have found the charts easy to use within the consultation and helpful as measures of overall patient status and as outcomes of care.

With any measure of functional status, cultural and context issues need to be explored. Some studies of the charts have suggested that they do not exhibit cross-cultural stability. As a research instrument the test-retest reliability will always be an issue for indicators that are global and influenced by so many variables. Several studies have looked at these issues. Standardisation of test conditions and assessment of inter-rater reliability may improve the results for research projects.

COOP/WONCA Charts

Through extensive testing in general/family practice settings, the current form of the COOP/WONCA charts was determined. There are now six charts: physical fitness; feelings; daily activities; social activities; change in health; and, overall health. A copy of the Chart is available at the bottom of this file.

Each chart consists of a lead sentence with five options for response. Pictorial depictions of the five possible responses accompany the text. These drawings have enhanced the applicability of these Charts in settings where there is variability of literacy amongst the general practice patient population.

To date the Charts have been published in the following languages: Chinese; Danish; Dutch; Finnish; French; German; Hebrew; Italian; Japanese; Korean; Norwegian; Portuguese; Spanish (Catalan; Castilian, and Callego); Slovak; Swedish and Urdu.

A manual has been edited by the University of Groningen.

Use of the Charts

The charts can be used independently or in groups. When more than one chart is used it is recommended that they are administered in the following order: physical fitness, feelings, daily activities, social activities, change in health, overall health. The preferred method of use of these charts is self administration. However, one study has shown a correlation between self-assessment and provider assessment. The average time for completion is less than five minutes.

When the charts are used in new cultural settings, it is important to establish that the concepts measured are appropriate and specific to that environment. Appropriate translation is the first step.

Measuring functional health status with the COOP/WONCA Charts: A Manual²⁷, provides further information about the development and use of the charts, how to translate the charts, and a contact list for further assistance, including authors of the various translations.

Relationship between ICPC and the COOP/WONCA Charts

Together with ICPC the COOP/WONCA charts can be used to explore the relationship between functionality and health problems. For example, Rubric 28 of component one (symptoms and complaints) of all chapters of ICPC refers to limited function and disabilities. Functional status could be coded in this component with the addition of an extra digit. However since functional status relates to the patient as a whole and not to the health problem, the relationship becomes difficult to interpret when there is more than one active problem, because co-morbidity complicates the interpretation. For example, hypertension and diabetes in one patient can both impact on functional status, but their relative importance and effects cannot be determined from routine recording. Even with only one problem, functional status measures go beyond assessing problem status and therefore their relationship a particular ICPC code may not be straightforward.

Manual with translation in several languages & Charts available at the bottom of this page