Kin 188 Record Keeping

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Kin 188 Record Keeping

  1. 1. KIN 188 – Prevention and Care of Athletic Injuries Record Keeping
  2. 2. Introduction <ul><li>Confidentiality and security items </li></ul><ul><li>Injury coding and insurance billing items </li></ul><ul><li>Injury evaluations and progress notes </li></ul>
  3. 3. Confidentiality <ul><li>Should be designated space for storage of medical records in facility </li></ul><ul><ul><li>“ Hard” copies (filing cabinet) vs. electronic </li></ul></ul><ul><li>Best if kept in secure environment (office or closet with lockable entrance) </li></ul><ul><ul><li>Key for office/closet or filing cabinet and password protected if electronic </li></ul></ul><ul><li>Access must be limited to sports medicine or allied health personnel only </li></ul>
  4. 4. Confidentiality <ul><li>HIPAA (Health Insurance Portability and Accountability Act) regulations </li></ul><ul><ul><li>Regulates how members of sports medicine team with access to private health information about an individual can share that with others </li></ul></ul><ul><ul><li>Guarantees individual’s have access to their medical records, gives them control of how their health information is used/disclosed and provides a path of recourse if medical privacy is compromised </li></ul></ul><ul><ul><li>Authorization for release of health information usually accomplished via blanket statement signed at start of year – must identify information to be released, to whom and for what length of time it’s effective </li></ul></ul>
  5. 5. Confidentiality <ul><li>FERPA (Family Educational Rights and Privacy Act) regulations </li></ul><ul><ul><li>Protects the privacy of student educational records – some debate regarding whether or not medical records should be kept with educational records and thus subject to FERPA regulations instead of HIPAA </li></ul></ul><ul><ul><li>Gives parents rights in respect to children’s educational records until age 18 when rights transfer to student </li></ul></ul><ul><ul><li>Must have authorization from student or parent to release records to others </li></ul></ul>
  6. 6. Insurance Billing <ul><li>When filing a claim for reimbursement for services, practitioners must complete a standardized HCFA-1500 form </li></ul><ul><ul><li>All HCFA forms must contain a diagnostic (ICD-9) code and a procedural (CPT) code </li></ul></ul><ul><ul><li>Accurate and thorough completion of all required information on these forms enhances the likelihood and rate of reimbursement to the provider </li></ul></ul>
  7. 7. Injury Coding <ul><li>ICD-9 (International Classification of Diseases) codes </li></ul><ul><ul><li>Each diagnostic code associated with a specific condition or injury that the health care provider is treating </li></ul></ul>
  8. 8. Injury Coding <ul><li>CPT (Current Procedure Terminology) codes </li></ul><ul><ul><li>Developed in 1966 by AMA – revised annually </li></ul></ul><ul><ul><li>Identifies specific medical procedures used in treating patients (e.g. - evaluation, ROM measurements, taping, etc.) </li></ul></ul><ul><ul><li>Each code associated with billing amount for reimbursement for services – amounts vary by region, insurance provider, etc. </li></ul></ul>
  9. 9. Injury Evaluation Records <ul><li>Most common method of recording injury evaluation results is SOAP note format </li></ul><ul><li>S – Subjective </li></ul><ul><ul><li>Statements from injured individual about the injury (History) </li></ul></ul><ul><li>O – Objective </li></ul><ul><ul><li>Results of clinical evaluation by provider (Inspection/Observation, Palpation, Special Tests) </li></ul></ul><ul><li>A – Assessment </li></ul><ul><ul><li>Professional judgment regarding impression and nature of injury </li></ul></ul><ul><li>P – Plan </li></ul><ul><ul><li>Short-term and long-term goals for treatment of injury </li></ul></ul><ul><ul><li>Typically involves first-aid, modalities, rehabilitation techniques, taping, referral, medications, etc. </li></ul></ul>
  10. 10. Progress Notes <ul><li>Should be completed after each follow-up evaluation during the course of treatment or rehabilitation </li></ul><ul><ul><li>Frequency of follow-up evaluations and, thereby, notes varies amongst injuries based upon individual circumstances </li></ul></ul><ul><li>Should identify treatments being administered, progress toward attaining short-term goals and any modifications made to treatment/rehab plan and goals </li></ul>

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