Documentation

Question 1

Why document

Answer 1

• legal protection
• memory aid
• legal requirements
• professional standards
• insurance requirements

Question 2

two kinds of information

Answer 2

• medical records

- program administration records

Question 3

Medical records

Answer 3

• physical examination forms
• injury eval/treatment forms
• referral form
• emergency information
• permission to treat

Question 4

Reports of special procedures

Answer 4

• strength testing
• blood tests
• UA
• x-reays/imaging
• reports
• surgical reports
• cardiac assesments

Question 5

Program administration records

Answer 5

• injury report for coaches
• budget information
• nonmusical correspondence
• equipment and supply information
• personnel information
• reporting information
• pt and student education materials

Question 6

medical record guidelines

Answer 6

• must be legible
• use permanent ink
• identify time, date on every entry
• sign each record
• describe findings objectively
• do not erase errors

Question 7

Guidelines

Answer 7

• write asap after care is given
• be factual and specific
• use pt. quotes
• chart only the care you provided

Question 8

Records storage

Answer 8

• easily accessible
• centralized: carbonless copy
• electric record-keeping
• must be stored securely

Question 9

Physical Exam form

Answer 9

• should be first in the medical record

- includes: personal data, past mdhx, vital signs, functional tests

Question 10

Five methods for documenting injury evaluation and treatment data

Answer 10

• problem oriented medical record
• focus charting
• charting by exception
• computerized documentation
• narrative charting

Question 11

Referral form

Answer 11

• provides legal proof the AT consulted with a physician as required
• athlete’s name, sport , injury date etc
• HIPAA compliance

Question 12

Emergency information

Answer 12

• easily accessible
• include insurance information
• travel

Question 13

Permission for medical treatment

Answer 13

• legal principle that individuals must consent to medical treatment
• maintained in medical record
• especially important in high school

Question 14

Release of medical information

Answer 14

• health care provider cannot release medical information with consent of the patient
• FERPA: edu records students do not have the legal right under FERPA to access their medical records
• HIPAA: in general, an AT works in environments subject to HIPAA rules
• we work under hipaa

Question 15

HIPAA

Answer 15

• obtain consent for treatment “notice of privacy practices”
• obtain authorization to release health information
• safe guard pt information
• release only the minimum necessary information

Question 16

Insurance information

Answer 16

• not part of a medical record
• different purposes and uses; confidentiality laws protect them in different ways
• do not put medical records supporting an insurance claim in the insurance folder

Question 17

Program Administration records

Answer 17

• more general than medical records and relate to the functioning of an athletic training program
• standards for confidentiality generally less than medical records
• maintain confidentiality

Question 18

Coach report

Answer 18

• daily written report of the health status of their athletes
• improves communication
• document recommendations for participation status
• confidentiality

Question 19

Program administration records

Answer 19

• budget information
• nonmusical correspondence
• equipment and supply information
• reporting information
• patient and student education information

Question 20

Filing medical records

Answer 20

• important to have an effective and appropriate system
• different settings require different filing systems
• medical and personnel records should be stored in a separate, locked cabinet
• 7 to 10 years

Question 21

Recommendations

Answer 21

• master outline of files in the entire system
• file labels
• do not overfill each file
• organize material in each file chronologically or alphabetically