Managing Information

Why is record Keeping Important? Legal Protection Legal Protection Memory/Communication Aid Memory/Communication Aid Legal requirement (OSHA) Legal requirement (OSHA) Professional Standard of Practice Professional Standard of Practice Insurance Requirement Insurance Requirement Discharge Decisions Discharge Decisions

Medical Records - Specific outline of the athletes health history during care Specific outline of the athletes health history during care Patient specific Patient specific Medical Specific Medical Specific

Medical Records guidelines Write Legibly (easy with computer records) Write Legibly (easy with computer records) Use permanent ink Use permanent ink For every entry identify the time, date and sign it For every entry identify the time, date and sign it Describe patients care Describe patients care Describe findings Describe findings Document changes in condition Document changes in condition Indicate patient/caregivers response to teaching Indicate patient/caregivers response to teaching

Medical Records guidelines Cont. Write entries chronologically Write entries chronologically Write entries shortly after care provided Write entries shortly after care provided Be factual & specific Be factual & specific Use patient quotes Use patient quotes Document patient complaints/needs/resolutions Document patient complaints/needs/resolutions Write what you say Write what you say (Avoid confusing quotes) (Avoid confusing quotes) Chart care provided Chart care provided

Forms in Medical Record - Basics Emergency information Emergency information Health History Health History Injury/Rehabilitation Evaluation (SOAP) Injury/Rehabilitation Evaluation (SOAP) Daily Treatment form Daily Treatment form Insurance Information Insurance Information

Medical Records - May also include Surgical/x-ray/MRI reports Surgical/x-ray/MRI reports Physician notes Physician notes Insurance Insurance Communication from other professionals Communication from other professionals Release of medical information form Release of medical information form Permission to provide medical treatment form Permission to provide medical treatment form

Injury/Rehabilitation Evaluation (SOAP NOTE) Subjective - athlete conveys symptoms Subjective - athlete conveys symptoms use quotes if possible use quotes if possible Objective - physical data observed Objective - physical data observed Use information such as 2+ strength Use information such as 2+ strength Assessment - Findings Assessment - Findings Plan - general outline Plan - general outline

Daily Records Many charting techniques Many charting techniques Focus charting Focus charting Charting by exception Charting by exception Somewhat outdated by computer technology Somewhat outdated by computer technology Computerized documentation Computerized documentation Individualized Individualized Commercial Commercial Dictation (Dragon) Dictation (Dragon)

Other Athletic Training/Sports Medicine Records Budgetary Budgetary Insurance Insurance Claims Claims Pay Pay Coaching reports Coaching reports May be on computer May be on computer Non-medical Correspondence Non-medical Correspondence Memorandum Memorandum

Other Athletic Training/Sports Medicine Records Equipment supply information (inventory) Equipment supply information (inventory) May be computerized May be computerized Personnel Information Personnel Information Student Education Information Student Education Information

Communication Records Insurance Insurance Do you need to notify administration (business manager)? Do you need to notify administration (business manager)? Physician Referral Physician Referral Outside University/Clinic Outside University/Clinic Health Center Health Center Coaches report Coaches report What do you include What do you include On paper or ? On paper or ?

Computer Hardware/Software Selection Hardware Hardware Compatible with school Compatible with school (front office?) (front office?) Enough RAM and MHz to expand with needs Enough RAM and MHz to expand with needs Software Software Capabilities? Capabilities? All forms on one database? All forms on one database? Compatibility with others in department/clinic Compatibility with others in department/clinic