Record Keeping

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Record Keeping

  1. 1. Record Keeping HuP 193
  2. 2. Why is record Keeping Important? <ul><li>Legal Protection </li></ul><ul><li>Memory/Communication Aid </li></ul><ul><li>Legal requirement (OSHA) </li></ul><ul><li>Professional Standard of Practice </li></ul><ul><li>Insurance Requirement </li></ul><ul><li>Discharge Decisions </li></ul>
  3. 3. Medical Records - <ul><li>Specific outline of the athlete’s health history during care </li></ul><ul><li>Patient specific </li></ul><ul><li>Medical Specific </li></ul>
  4. 4. Medical Records guidelines <ul><li>Write Legibly (easy with computer records) </li></ul><ul><li>Use permanent ink or computer with PIN </li></ul><ul><li>For every entry identify the time,date and signature or computer PIN </li></ul><ul><li>Describe patient’s care </li></ul><ul><li>Describe findings </li></ul><ul><li>Document changes in condition </li></ul><ul><li>Indicate patient/caregivers response to teaching </li></ul>
  5. 5. Medical Records guidelines Cont. <ul><li>Write entries reverse chronologically </li></ul><ul><li>Write entries shortly after care provided </li></ul><ul><li>Be factual & Specific </li></ul><ul><li>Use patient quotes </li></ul><ul><li>Document patient complaints/needs/resolutions </li></ul><ul><li>Write what you say (Avoid confusing quotes) </li></ul><ul><li>Chart care provided </li></ul>
  6. 6. Forms in Medical Record - Basics <ul><li>Emergency information </li></ul><ul><li>Health History </li></ul><ul><li>Injury/Rehabilitation Evaluation (SOAP) </li></ul><ul><li>Daily Treatment form </li></ul><ul><li>Insurance Information </li></ul>
  7. 7. Medical Records - May also include <ul><li>Surgical/x-ray/MRI reports </li></ul><ul><li>Physician notes </li></ul><ul><li>Insurance </li></ul><ul><li>Communication from other professionals </li></ul><ul><li>Release of medical information form </li></ul><ul><li>Permission to provide medical treatment form </li></ul>
  8. 8. Injury/Rehabilitation Evaluation (SOAP NOTE) <ul><li>Subjective - athlete conveys symptoms </li></ul><ul><ul><li>use quotes if possible </li></ul></ul><ul><li>Objective - physical data observed </li></ul><ul><ul><li>Use information such as “2+ strength” </li></ul></ul><ul><li>Assessment - Findings </li></ul><ul><li>Plan - general outline </li></ul>
  9. 9. Daily Records <ul><li>Many charting techniques </li></ul><ul><ul><li>Focus charting </li></ul></ul><ul><ul><li>Charting by exception </li></ul></ul><ul><ul><li>Somewhat outdated by computer technology </li></ul></ul><ul><li>Computerized documentation: SIMS, Simtrack, PITS, Filemaker Pro, Outlook Etc… </li></ul><ul><ul><li>individualized </li></ul></ul><ul><ul><li>commercial </li></ul></ul><ul><ul><li>Dictation </li></ul></ul>
  10. 10. Other Athletic Training/Sports Medicine Records <ul><li>Budgetary </li></ul><ul><li>Insurance </li></ul><ul><ul><li>Claims </li></ul></ul><ul><ul><li>Pay </li></ul></ul><ul><li>Coaching reports </li></ul><ul><ul><li>May be on computer </li></ul></ul><ul><li>Non-medical Correspondence </li></ul><ul><ul><li>Memorandum </li></ul></ul>
  11. 11. Other Athletic Training/Sports Medicine Records <ul><li>Equipment supply information (inventory) </li></ul><ul><ul><li>May be computerized </li></ul></ul><ul><ul><li>Personnel Information </li></ul></ul><ul><ul><li>Student Education Information </li></ul></ul>
  12. 12. Communication Records <ul><li>Insurance </li></ul><ul><ul><li>Do you need to notify administration (business manager) </li></ul></ul><ul><li>Physician Referral </li></ul><ul><ul><li>Outside University/Clinic </li></ul></ul><ul><ul><li>Health Center </li></ul></ul><ul><li>Coaches report </li></ul><ul><ul><li>What do you include </li></ul></ul><ul><ul><li>On paper or e-mail? </li></ul></ul>
  13. 13. Computer Hardware/Software Selection <ul><li>Hardware </li></ul><ul><ul><li>compatible with university (Front Office?) </li></ul></ul><ul><ul><li>Enough RAM and MHz to expand with needs </li></ul></ul><ul><li>Software </li></ul><ul><ul><li>Capabilities? </li></ul></ul><ul><ul><li>All forms on one database? </li></ul></ul><ul><ul><li>Compatibility with others in department/clinic </li></ul></ul>

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