Medical

Records

Sports Medicine

9/18/2015 1

Bellwork

Imagine the following scenario: You make

an appointment with your doctor for

your yearly physical and show up at the

right time and date, only to find that the

office has no record of your appointment.

They also have no record of your past

medical history on file, so you have to fill

out the new patient forms. Then you have

to reschedule an appointment since they

have no record of today’s appointment.9/18/2015 Property of CTE Joint Venture 2

Bellwork (cont.)

Please think about the following and be

prepared to share your responses with

the rest of the class.

1. Describe how you would feel if you

found yourself in the situation from the

previous slide.

2. Why is it important to keep accurate

medical records?

9/18/2015 Property of CTE Joint Venture 3

Objectives

1. Identify reasons for keeping medical

records

2. Distinguish between different types of

medical records

3. Create a medical record using

information provided

9/18/2015 Property of CTE Joint Venture 4

Graphic Organizer

PROPERTY OF PIMA COUNTY JTED, 2010 5

Write down information from the

text or presentation into your

graphic organizer

Why keep medical records?

1. Required part of an AT’s professional

practice

2. Communication purposes

3. Legal responsibility

4. Research

5. ROI

6. Reimbursement

9/18/2015 Property of CTE Joint Venture 6

The Facts About Medical Records

Create a detailed, chronological ‘story’ of

a patient’s interaction with health care

providers.

Explain why decisions were made, what

care was provided, and what outcome

was outcome

Help plan and evaluate treatments and

monitor progress

9/18/2015 Property of CTE Joint Venture 7

Identification

Highlight the

different types of

medical records

PROPERTY OF PIMA COUNTY JTED, 2010

Terminology

pre-participation physical

examination (PPE)

◦ a checkup to evaluate a person’s health and

determine if they are able to participate in

sports

9/18/2015 Property of CTE Joint Venture 9

Types of medical records

1. Medical information forms

Personal medical history

Family medical history

Orthopedic history

Pre-participation physical examination (PPE)

2. Injury evaluation form

3. Treatment form

4. Referral form

9/18/2015 Property of CTE Joint Venture 10

Injury Scenario – Part 1

You are an ATSA watching a freshman

boys’ basketball game. You see one of the

players come down and land on another

player’s foot. His ankle is forced into

inversion; he says that he heard a pop.

This is the 2nd time he has injured his R

ankle; the first time was last year while

playing basketball. The athlete is unable to

bear weight.

9/18/2015 Property of CTE Joint Venture 11

Injury Scenario – Part 2

Under the AT’s direction, you observe

that the athlete’s ankle is swollen around

the lateral malleolus. There is no

discoloration or obvious ankle deformity.

During palpation, you note that the

athlete is point tender over the anterior

talofibular and calcaneofibular ligaments.

His capillary refill is good and he has a

strong dorsal pedis pulse.

9/18/2015 Property of CTE Joint Venture 12

Injury Scenario – Part 3

Athlete’s motion in dorsiflexion and

inversion are limited by pain; you do not

test his strength at this time because of

pain.

Your evaluation is as follows:

(-) compression and bump tests

(+) anterior drawer test

(-) talar tilt in inversion

(+) talar tilt in eversion

9/18/2015 Property of CTE Joint Venture 13

Injury Scenario – Part 4

Since the athlete is unable to bear weight,

you do not do any functional testing at

this time.

You follow the RICE protocol for soft

tissue injuries. After icing/elevating for 20

minutes, you apply an Ace wrap for

compression and instruct athlete on the

use of crutches – NWB. You also instruct

the athlete to report to the training room

tomorrow after school.9/18/2015 Property of CTE Joint Venture 14

PROPERTY OF PIMA COUNTY JTED, 2010 15

Snapshot

Write a

“snapshot” of

today’s learning

about medical

records in 25

words or less.