Record Keeping

HuP 193

Why is record Keeping Important?

Legal ProtectionMemory/Communication AidLegal requirement (OSHA)Professional Standard of PracticeInsurance RequirementDischarge Decisions

Medical Records -

Specific outline of the athlete’s health history during care

Patient specificMedical Specific

Medical Records guidelines

Write Legibly (easy with computer records) Use permanent ink or computer with PIN For every entry identify the time,date and

signature or computer PIN Describe patient’s care Describe findings Document changes in condition Indicate patient/caregivers response to

teaching

Medical Records guidelines Cont.

Write entries reverse chronologically Write entries shortly after care provided Be factual & Specific Use patient quotes Document patient

complaints/needs/resolutions Write what you say (Avoid confusing quotes) Chart care provided

Forms in Medical Record - Basics

Emergency informationHealth HistoryInjury/Rehabilitation Evaluation (SOAP)Daily Treatment formInsurance Information

Medical Records - May also include

Surgical/x-ray/MRI reportsPhysician notesInsurance Communication from other professionalsRelease of medical information formPermission to provide medical treatment

form

Injury/Rehabilitation Evaluation (SOAP NOTE)Subjective - athlete conveys symptoms

use quotes if possible

Objective - physical data observed Use information such as “2+ strength”

Assessment - FindingsPlan - general outline

Daily Records

Many charting techniques Focus charting Charting by exception Somewhat outdated by computer technology

Computerized documentation: SIMS, Simtrack, PITS, Filemaker Pro, Outlook Etc… individualized commercial Dictation

Other Athletic Training/Sports Medicine RecordsBudgetaryInsurance

Claims Pay

Coaching reports May be on computer

Non-medical Correspondence Memorandum

Other Athletic Training/Sports Medicine RecordsEquipment supply information (inventory)

May be computerized Personnel Information Student Education Information

Communication Records

Insurance Do you need to notify administration (business

manager)

Physician Referral Outside University/Clinic Health Center

Coaches report What do you include On paper or e-mail?

Computer Hardware/Software SelectionHardware

compatible with university (Front Office?) Enough RAM and MHz to expand with needs

Software Capabilities? All forms on one database? Compatibility with others in department/clinic