Documenting In Sports Medicine

Why Document  Legal Protection-Provides a written record of treatments so that if recall is needed there is concrete evidence to back it up  Memory Aid-It may come as a surprise but human memory is not the best when recalling treatments, using documentation alleviates the need.  Legal Requirement-Most health care professions are required by law.  Professional Standards-Professional credentials may require that medical documentation be apart of the profession

What to Document  Two main types of information to document  Medical Records-patient specific data that should directly reflect the patients health.  Guidelines:  Write legibly, Use permanent ink, always id time, and date, sign each entry, describe care provided  Describe Findings, Write entries in chronological order, Make entries ASAP, Be specific  Use patient quotes, Documents patient complaints, Write out what you are saying  Chart only care provided, promptly write down any changes in the patient in response to treatment

What to Document  Medical Records cont….  Information contained in the medical records  Physical Examination Form  Injury Evaluation and treatment forms  SOAP Notes  Computer documentation  Diagnostic tests  Communications from other professionals  Emergency Information  Permission to provide medical treatment forms  Release of medical information forms  Insurance information

What to Document  Program Administration Records  Reports to Coaches  Budget information  Nonmedical correspondence  Equipment and supply information  Personal Information  Patient and Student Education

Writing A SOAP Note  Key piece of information all health care professionals should be proficient at is writing a SOAP Note  SOAP stands for  Subjective-Relates to how the patient conveys symptoms, what they tell you  Objective-physical data actually observed by the professional  Assessment-the professionals judgement as what's wrong based off of the subjective and objective parts of the note  Plan-Refers to the course of action that will be taken to remedy the patients chief complaints

Writing a SOAP NOTE  Directions: Take the below information and place it in the proper area on your handout.  Continue Treatment for 2x a week for 3 weeks  Complains of pain after every breath  Large hematoma on right upper shoulder  BP is 125/77  Says that light stretching makes hamstring “twitch” after completed  Increase number of exercises this week  Says that their knee feels like it wants to “give out” when going down stairs  Refer to orthopedic for further evaluation  MRI results show no obvious deformity within the capsule  Pulse is at 82 beats per minute

Writing a SOAP Note  Patient says that every time they run they begin to feel “dizzy” and need to sit down  CC is loss of movement in their right ankle  Walked into clinic with heavy limp and favoring left ankle  Large open wound to the mid torso  Pack with gauze and keep covered for the length of treatment time  Possible inversion ankle sprain to the right ankle  Begin crutch walking education with patient  Exercises should focus on range of motion for the next 3 visits  Patient says pain is a 6 out of 10 on pain scale  X-ray report identifies possible fracture of the fifth metacarpal