The Athletic Trainer as a Record Keeper a.k.a – all the paperwork

So why do we do all this paperwork? There are two main reasons for careful record keeping: Can be used to determine trends and try to prevent further injuries Protects you, the team, and the school from legal action in the event of a serious injury.

HIPAA - what on earth is that?? HIPAA – Health Insurance Portability and Accountability Act. This is a law that protects the privacy of all athletes/patients. As a medical professional, you cannot share any medical records or personal information about any athlete/patient, without written consent.

Here’s where we are different… When you go to the doctor’s office, where do they bring you to be evaluated? If you get hurt on the field, where are you initially evaluated? In a doctors office, you will be in a small evaluation room that has no windows visible to public. On the field, there are your teammates, coaches, opposing team, and spectators all watching…so your medical evaluation is completely public ***Use the story that I was evaluating someone on the sideline and had a “doctor” come down from stands and try to tell me what he thought was wrong just from seeing my evaluation from the stands.

So what types of records do we keep? Injury Reports* Emergency Insurance Information Pre-participation Physical Evaluation* Consent forms/Risk Acknowledgement* Emergency Action Plan Sign-in sheets Will discuss those further that are starred. Emergency Insurance Information – will provide all insurance information needed to treat an injured athlete. MUST be in athlete’s file and should travel to away competitions. Athletes are not allowed to participate without this!!! Emergency Action Plan – lists all the procedures that will be followed by all relevant personnel. We might discuss this further later but it is always develop prior to the start of the season and all necessary staff are made aware of their responsibilities so things happen smoothly in an emergency situation. Sign-in sheets – just another way to cover yourself legally. Also shows that athletes are fulfilling their role in seeking treatment, rehab, etc.

Athlete info (Name, DOB, sport) Injury information The Injury Report What does it usually include? Athlete info (Name, DOB, sport) Injury information Body part, L or R, type of injury, etc Treatment given/action taken Removed from play, given ice, immobilized, etc Referral (not the type you’ve heard of…) Sent to ER, sent home, referred to team physician Any other relevant information

The Pre-participation Physical Eval. Completed by athlete and doctor Primary purpose is to determine if any athlete has a pre-existing injury or illness that may affect his/her ability to participate in the sport without limitations. Medical and coaching staffs both need to know about any of these conditions. Doesn’t necessarily eliminate that athlete’s possibility to play, just helps make play safer.

Consent form/ Risk acknowledgement All athletes assume a risk by participating in a sport Athletes and a parent/guardian (if under 18), must sign a form acknowledging that risk. This form releases the sports medicine team from liability in the event of injury. It does NOT cover negligence. (If an injury is ignored or made worse by the care given, the caregiver is at risk for legal action.

Truth?? Ask any Athletic Trainer…. They will tell you this is their least favorite part of their job. But we love our jobs anyway!! Thanks for listening!!!!