Transcript Record Keeping

Managing Information
Why is record Keeping
Important?
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Legal Protection
Memory/Communication Aid
Legal requirement (OSHA)
Professional Standard of
Practice
Insurance Requirement
Discharge Decisions
Medical Records 
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Specific outline of the athlete’s
health history during care
Patient specific
Medical Specific
Medical Records guidelines
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Write Legibly (easy with computer
records)
Use permanent ink
For every entry identify the time, date
and sign it
Describe patient’s care
Describe findings
Document changes in condition
Indicate patient/caregivers response
to teaching
Medical Records guidelines
Cont.
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Write entries 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
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Emergency information
Health History
Injury/Rehabilitation Evaluation
(SOAP)
Daily Treatment form
Insurance Information
Medical Records - May also
include
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Surgical/x-ray/MRI reports
Physician notes
Insurance
Communication from other
professionals
Release of medical information
form
Permission to provide medical
treatment form
Injury/Rehabilitation
Evaluation (SOAP NOTE)
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Subjective - athlete conveys
symptoms
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Objective - physical data
observed
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use quotes if possible
Use information such as “2+
strength”
Assessment - Findings
Plan - general outline
Daily Records
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Many charting techniques
Focus charting
 Charting by exception
 Somewhat outdated by computer
technology
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Computerized documentation
Individualized
 Commercial
 Dictation (Dragon)
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Other Athletic Training/Sports
Medicine Records
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Budgetary
Insurance
Claims
 Pay
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Coaching reports
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May be on computer
Non-medical Correspondence
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Memorandum
Other Athletic Training/Sports
Medicine Records
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Equipment supply information
(inventory)
May be computerized
 Personnel Information
 Student Education Information
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Communication Records
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Insurance
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Do you need to notify
administration (business
manager)?
Physician Referral
Outside University/Clinic
 Health Center
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Coaches report
What do you include
 On paper or e-mail?
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Computer Hardware/Software
Selection
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Hardware
Compatible with school
(front office?)
 Enough RAM and MHz to expand
with needs
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Software
Capabilities?
 All forms on one database?
 Compatibility with others in
department/clinic
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