Transcript Chapter 3 Presentation

Chapter 3. Injury Record Keeping
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Injury Record Keeping
Accurate and detailed record
keeping is a mandatory part of any
athletic program.
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Why Keep Records?
Communication and quality control
Legal considerations
Research
Injury history
Traffic patterns
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Communication and Quality
Control
This is by far the most important reason
for keeping records.
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Communication and Quality
Control (cont.)
With . . .
Self
Others involved in the case, and
Athlete
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Communication with Self
It is hard to keep all the details of individual
cases straight without written records.
A periodic review of cases helps you see
progress.
A review may stimulate ideas for improved
treatment.
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Communication with Others
All members of the team should know what the others have
done, creating continuity.
Without records, the efforts of each will be isolated rather than
being part of a coordinated whole.
It is confusing to an athlete to get conflicting advice about his or
her problem.
(Used with permission from Castel D.
International Academy of Physio
Therapeutics. Clip art.)
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Communication with Others
(cont.)
A physician’s efforts are often more
efficacious if he or she receives detailed
information.
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Communication with Athlete
Keeps athlete honest—that is, makes
the athlete more compliant with
rehabilitation program.
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Legal Considerations
The value of a document depends on its
accuracy and detail.
Most lawsuits occur years after the
event, usually after the memory of
specific details is gone.
Written records supply memory.
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Research
To provide memory so you can compare
efficacy of treatments
Thus improve methods
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History
Specific and detailed information is
important to a variety of people:
Insurance company
College and professional recruiters
Military
Some employers
Need for information often occurs months
after the injury occurred
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Traffic Patterns
Establish daily, weekly, monthly, and yearly
traffic patterns.
Such records can be the clincher in verifying
the need for additional facilities and/or staff
or in preventing cuts in the program.
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What Records Should Be
Kept
Medical information
Incoming student athlete
Returning student athlete
Injury evaluation
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What Records Should Be
Kept (cont.)
1. Evaluation of Injuries
a. Athletic injury report form
2. Treatment of Injuries
a. Daily treatment log
b. Individual treatment sheet
c. Daily weight-recording form
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What Records Should Be
Kept (cont.)
3. Referrals to and from others
a. Medical referral
b. Rehabilitation referral
4. Medical Information
a. Incoming student athlete
b. Returning student athlete
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What Records Should Be
Kept (cont.)
5. Equipment Upkeep
a. Ultrasound calibration
b. E-stim maintenance
c. GFI check
d. Weight equipment maintenance
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Initialing Forms
Every entry should be initialed by the
person making the entry.
This lets people know who to go to for
additional information.
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SOAP Notes
SOAP is an
acronym;
each letter
represents a
section of the
patient note.
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SOAP Notes (cont.)
S: Subjective
► Information gathered primarily from
questioning the athlete about his or her
present condition
Example: “I twisted my ankle, and it hurts right
here.”
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SOAP Notes (cont.)
O: Objective
► Reproducible information the athletic trainer
gathers through tests or other evaluative
measures
Examples: laxity stress tests, girth, volumetric
tests, ROM
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SOAP Notes (cont.)
A: Assessment
► Clinician’s professional judgment or
impression of the injury
Example: second-degree inversion ankle sprain
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SOAP Notes (cont.)
P: Plan
► Course of action that the athletic trainer and
the patient will take to treat and rehabilitate
the injury; includes both short- and long-term
goals
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