Record Keeping Major responsibility The rule not the exception - accurate and up-to-date Medical records, injury reports, insurance information, injury evaluations, progress notes, equipment inventories, annual reports

Maintaining Confidentiality in Record Keeping Health Insurance Portability and Accountability Act (HIPAA) –Regulates dissemination of personal history information (PHI) by coaches, ATC’s, physicians or other members of sports medicine team –Guarantees athlete access to information and control over disclosure –Athlete may provide written authorization for release of information

HIPAA Authorization –Description of information to be disclosed –Identification of parties authorized to provide and make use of PHI –Description of each purpose of the use or disclosure –Expiration date or event –Individual’s signature –Description of his/her authority to act for the individual if signed by personal representative

Family Educational Rights and Privacy Act –FERPA = law protecting privacy of student education records –Provides parents with certain rights with respect to child’s educational records –When child turns 18 rights are transferred to student –School must have written permission prior to releasing information

Administering Pre-participation Examinations Initial pre-participation exam prior to start of practice is critical Purpose it to identify athlete that may be at risk Should include –Medical history, physical exam, orthopedic screening, wellness screening Establishes a baseline Satisfies insurance and liability issue

Examination by Personal Physician –Yields an in-depth history and ideal physician-patient relationship –May not result in detection of factors that predispose the athlete to injury Station Examination –Provides athlete with detailed exam in little time –Team of nine is ideal (2 physicians, 2 non- physicians and 5 managers/student athletic trainers)

Medical History –Complete prior to exam to identify past and existing medical conditions –Update yearly and closely review by medical personnel –Collect medical release and insurance info at the same time Physical Examination –Should include assessment of height, weight, body composition, blood pressure, pulse, vision, skin, dental, ear, nose, throat, heart, lungs, abdomen, lymphatic, genitalia, maturation index, urinalysis and blood work

Maturity Assessment –Means to protect young physically active athletes –Methods Circumpubertal (sexual maturity) Skeletal Dental –Tanner’s five stage assessment is most expedient Orthopedic Screening –Part of physical exam or separate –Various degrees of detail concerning exam

Wellness Screening –Purpose is to determine if athlete is engaged in a healthy lifestyle Sport Disqualification –Certain injuries and illnesses warrant special concern when dealing with sports –Recommendations can be made –American with Disabilities Act (1990) Dictates that athlete makes the final decision –Potential disqualifying factors should be determined during the pre-participation exam

Injury Reports and Injury Disposition Injury reports serve as future references Reports can shed light on events that may be hazy following an incident Necessary in case of litigation All reports should be filed in the athletic training room

Treatment Log Sign-in to keep track of services Daily treatments can be recorded Can be used as legal documentation in instances of litigation Personal Information Card Contains contact information for family, personal physician, and insurance information

Injury Evaluation and Progress Notes Injuries and progress should be monitored by athletic trainer and recorded SOAP note format –S: Subjective (history of injury/illness) –O: Objective (information gathered during evaluation) –A: Assessment (opinion of injury based on information gained during evaluation) –P: Plan (short and long term goals of rehab)

Supplies and Equipment Inventory Managing budget and equipment/supplies is critically important Inventory must be taken yearly in order to effectively replenish supplies

Annual Report Summary of athletic training room functions Can be used to evaluate recommend potential changes for program Includes number and types of injuries seen/treated

Release of Medical Records Written consent is required Waiver must be signed for any release (include specifics of information to be released and to whom)

Computer as Tool for Athletic Trainer Indispensable tool Can make the job more efficient with appropriate software Must maintain security Must determine for what computer will be used

Should consult experts in order to determine what systems are appropriate for specific use Factors to consider –Access to mainframe and internet –Hardware (desktop, laptop, personal digital assistants) –Software – various programs for multiple uses Record keeping needs Word processing, budget maintenance Educational software –World Wide Web and access to

Collecting Injury Data Accident - unplanned event resulting in loss of time, property damage, injury or death Injury- damage to the body restricting activity Case study- looks at specific incident of injury

Epidemiologic studies may assess various areas –Age or gender –Body part –Occurrence in different sports –Contact, non-contact, limited contact, collision sports

Catastrophic Injuries –98% of injuries requiring hospital emergencies are treat and release relative to sport –Sports deaths (struck with object, heat stroke) –Catastrophic injuries also include spinal cord trauma, cardiorespiratory injuries/problems –Most injuries are related to appendages Strains, sprains, contusions, fractures, abrasions

Current National Injury Data-Gathering Systems –State of the art injury surveillance is still developing –Ideal situation Epidemiological approach that studies relationship of various factors that influence frequency and distribution of injury in sport Extrinsic factors (activity, exposure, equipment) Intrinsic factors (age, gender, neuromuscular aspects, structural aspects….etc) –Number of different surveillance systems in place

Surveillance Systems –National Safety Council General sports injury data –Annual Survey of Football Injury Research Public school, college, professional, sandlot football injury data –National Center of Catastrophic Sport Injury Research Tracks catastrophic injuries in all levels of sports

–NCAA Injury Surveillance System Data collected on most major sports- ATC data collection Converted to web-based data collection system –National Electronic Injury Surveillance System Monitor injuries relative to different products -- consumer safety, determine if products are hazardous or defective

Using Injury Data Valid and reliable data can be utilized to decrease injuries May allow for: –Rule modification –Assist coaches and players in understanding risks –Help manufacturers –Educate parents, athletes and the public on inherent risks associated with sport