KIN 188 – Prevention and Care of KIN 188 – Prevention and Care of Athletic InjuriesAthletic Injuries

Record KeepingRecord Keeping

IntroductionIntroduction

Confidentiality and security itemsConfidentiality and security items

Injury coding and insurance billing itemsInjury coding and insurance billing items

Injury evaluations and progress notesInjury evaluations and progress notes

ConfidentialityConfidentiality Should be designated space for storage of medical Should be designated space for storage of medical

records in facilityrecords in facility– ““Hard” copies (filing cabinet) vs. electronicHard” copies (filing cabinet) vs. electronic

Best if kept in secure environment (office or closet Best if kept in secure environment (office or closet with lockable entrance)with lockable entrance)– Key for office/closet or filing cabinet and password Key for office/closet or filing cabinet and password

protected if electronicprotected if electronic

Access must be limited to sports medicine or Access must be limited to sports medicine or allied health personnel onlyallied health personnel only

ConfidentialityConfidentiality HIPAA (Health Insurance Portability and HIPAA (Health Insurance Portability and

Accountability Act) regulationsAccountability Act) regulations– Regulates how members of sports medicine team with Regulates how members of sports medicine team with

access to private health information about an individual access to private health information about an individual can share that with otherscan share that with others

– Guarantees individual’s have access to their medical Guarantees individual’s have access to their medical records, gives them control of how their health records, gives them control of how their health information is used/disclosed and provides a path of information is used/disclosed and provides a path of recourse if medical privacy is compromisedrecourse if medical privacy is compromised

– Authorization for release of health information usually Authorization for release of health information usually accomplished via blanket statement signed at start of accomplished via blanket statement signed at start of year – must identify information to be released, to year – must identify information to be released, to whom and for what length of time it’s effectivewhom and for what length of time it’s effective

ConfidentialityConfidentiality

FERPA (Family Educational Rights and Privacy FERPA (Family Educational Rights and Privacy Act) regulationsAct) regulations– Protects the privacy of student educational records – Protects the privacy of student educational records –

some debate regarding whether or not medical records some debate regarding whether or not medical records should be kept with educational records and thus should be kept with educational records and thus subject to FERPA regulations instead of HIPAAsubject to FERPA regulations instead of HIPAA

– Gives parents rights in respect to children’s educational Gives parents rights in respect to children’s educational records until age 18 when rights transfer to studentrecords until age 18 when rights transfer to student

– Must have authorization from student or parent to Must have authorization from student or parent to release records to othersrelease records to others

Insurance BillingInsurance Billing

When filing a claim for reimbursement for When filing a claim for reimbursement for services, practitioners must complete a services, practitioners must complete a standardized HCFA-1500 formstandardized HCFA-1500 form– All HCFA forms must contain a diagnostic All HCFA forms must contain a diagnostic

(ICD-9) code and a procedural (CPT) code(ICD-9) code and a procedural (CPT) code– Accurate and thorough completion of all Accurate and thorough completion of all

required information on these forms enhances required information on these forms enhances the likelihood and rate of reimbursement to the the likelihood and rate of reimbursement to the providerprovider

Injury CodingInjury Coding

ICD-9 (International Classification of ICD-9 (International Classification of Diseases) codesDiseases) codes– Each diagnostic code associated with a specific Each diagnostic code associated with a specific

condition or injury that the health care provider condition or injury that the health care provider is treatingis treating

Injury CodingInjury Coding

CPT (Current Procedure Terminology) CPT (Current Procedure Terminology) codescodes– Developed in 1966 by AMA – revised annuallyDeveloped in 1966 by AMA – revised annually– Identifies specific medical procedures used in Identifies specific medical procedures used in

treating patients (e.g. - evaluation, ROM treating patients (e.g. - evaluation, ROM measurements, taping, etc.)measurements, taping, etc.)

– Each code associated with billing amount for Each code associated with billing amount for reimbursement for services – amounts vary by reimbursement for services – amounts vary by region, insurance provider, etc.region, insurance provider, etc.

Injury Evaluation RecordsInjury Evaluation Records Most common method of recording injury evaluation Most common method of recording injury evaluation

results is SOAP note formatresults is SOAP note format S – SubjectiveS – Subjective

– Statements from injured individual about the injury (History)Statements from injured individual about the injury (History) O – ObjectiveO – Objective

– Results of clinical evaluation by provider (Inspection/Observation, Results of clinical evaluation by provider (Inspection/Observation, Palpation, Special Tests)Palpation, Special Tests)

A – AssessmentA – Assessment– Professional judgment regarding impression and nature of injuryProfessional judgment regarding impression and nature of injury

P – PlanP – Plan– Short-term and long-term goals for treatment of injuryShort-term and long-term goals for treatment of injury– Typically involves first-aid, modalities, rehabilitation techniques, Typically involves first-aid, modalities, rehabilitation techniques,

taping, referral, medications, etc.taping, referral, medications, etc.

Progress NotesProgress Notes Should be completed after each follow-up Should be completed after each follow-up

evaluation during the course of treatment or evaluation during the course of treatment or rehabilitationrehabilitation– Frequency of follow-up evaluations and, thereby, notes Frequency of follow-up evaluations and, thereby, notes

varies amongst injuries based upon individual varies amongst injuries based upon individual circumstancescircumstances

Should identify treatments being administered, Should identify treatments being administered, progress toward attaining short-term goals and any progress toward attaining short-term goals and any modifications made to treatment/rehab plan and modifications made to treatment/rehab plan and goalsgoals