Transcript Chapter 8 Medical Records - McGraw Hill Higher Education

Athletic Training
Management
Chapter 17
Medical Records
© 2006 McGraw-Hill Higher Education. All rights reserved.
Medical Records
 Record
keeping in medical settings
involves information from personal,
financial, and medical data.
 Personal data includes name, address,
DOB, sex, personal physician, emergency
contact, and any other identifying info
 Financial data includes who will pay the
bills, employer, insurances with policy
numbers
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Medical Records
 Medical
info are written in a
comprehensive clinical record that gives a
continuously updated history of the
treatment rendered, reasons for the
treatment, physician of record for each
incident, physical examinations, medical
histories, X-ray reports, laboratory
findings, consultation reports, progress
notes, and signed consent forms, among
other information
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Medical Records

Each state has a legal definition of a medical record in
their laws. An example:

For each patient there shall be an adequate, accurate, timely,
and complete medical record. Minimum requirements for medical
record content are as follows: patient identification and
admission information; history of patient as to chief complaints,
present illness and pertinent past history, family history, and
social history; physical examination report; provisional diagnosis;
diagnostic and therapeutic reports on laboratory test results, Xray findings, any surgical procedure performed, any pathological
examination, any consultation, and any other diagnostic or
therapeutic procedure performed; orders and progress notes
made by the attending physician and when applicable by other
members of the medical staff and allied health personnel;
observation notes and vital sign charting made by nursing
personnel; and conclusions as to the primary and any associated
diagnosis, brief clinical resume, disposition at discharge to
include instructions and/or medications and any autopsy findings
on a hospital death. (Illinois Hospital Licensing Requirements
¤12-1.2[b] [1979])
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Medical Records

BOC has established 15 Standards of
Professional Practice.
 Standard 3 deals with documentation and states
documentation must include:
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1. Athlete’s name and any other identifying
information.
2. Referral source (doctor, dentist).
3. Date; initial assessment, results and database.
4. Program plan and estimated length.
5. Program methods, results and revisions.
6. Date of discontinuation and summary.
7. Athletic trainer’s signature.
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Medical Records
 Length
of time these records must be kept
varies from state to state with the statute
of limitations, between 1 and 8 years
 Remember the statute is not running when
an individual does not know there is a
problem (see Chapter 8 p 115)
 In some states the time limit does not start
until the discovery of the malpractice
which could be 15 to 20 years after the
fact
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Medical Records
 Safest
length of time to keep records is
until the death of the patient
 For minors remember the statute of
limitations may not begin until they turn 18
years of age
 Files of athletes who go on to professional
sports should be retained for at least their
professional career for use during worker’s
compensation cases
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Necessity of Records
 There
is great variability in the quality of
records in different settings
 Clinics and most outreach clinic
employees stick to the hospital standard
 Professional sports documents well due to
worker’s compensation standards
 College/university setting is variable from
excellent to very poor
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Necessity of Records
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This is in part because most colleges treat
each incident as a new patient with all
treatments and procedures entered on the
record of that particular injury
Copies of the forms may be appended as
needed to physician’s records
Recent court decisions have shown that
having proper treatment records is a major
factor in successful outcomes in court
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Necessity of Records
 Primary

reasons for records
Communication
• Formal or informal
• Most communication should be considered formal
including all recommendations, discussions,
evaluations and the like
• Written record is vastly preferable to oral
communication
• Often treatment are administered by different
people from one session to the next
• If treatments are not recorded no one knows what
the others are doing
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Necessity of Records
• This leads to confusion on the part of the athlete,
especially if different ATs are giving different advice
and supervising different rehab sessions inhibiting
consistency and efficiency

Legal
• Necessary to have an accurate, comprehensive
record of each athlete

Defense against negligence action
• Many cases claim the defendant failed to provide
adequate information on the diagnosis, reporting,
etc. between the consulting and primary healthcare
provider
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Necessity of Records
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When a defendant testifies from a written record it has
greater impact than saying I know the plaintiff only made
about half of the scheduled appointments
Secondary reasons
• Research
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Case reports for literature
Data to justify request for additional staff, scheduling,
request for additional equipment, etc.
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Necessity of Records
• Insurance documentation
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AT has a CPT code
CPT = current procedural terminology
CPT must be authorized for a particular
diagnosis
IDC-9 code is the International Diagnostic Code
which identifies everything that can happen to a
person
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Constructing the Written Record
 Most
common styles are narrative,
problem-oriented, anecdotal, and SOAP
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Narrative allows explanation of problems
• Disadvantage is quantity of words a reader has to
wade through to get to the problem

Problem oriented styles prioritize issues and
groups data into subheadings
• Used in clinics

Anecdotal data is entered into a preprinted
form with minimal narrative entered into
various spaces
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Constructing the Written Record

SOAP is most common (we’ll come back to
this)
 Common

sense principles
Records must be kept at multiple sites
• What happens in a fire?
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Patient’s name must be on top of every piece
of paper in the file
Each entry must be in ink and signed and
dated
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Constructing the Written Record

Language must be specific, objective,
concise, and precise in all details
• Document the WHY as well as the what
• Document all adverse reactions
• Proper medical terminology
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All entries in a timely fashion and accurate
and legible
Contradictions are a potential disaster
• All corrections must take care to preserve the
readability of the original record
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Constructing the Written Record
• Reasons for the change must be stated
• Signatures required
• Liquid paper, cross-outs, or other damage to the
original allow the plaintiff to claim the record was
altered to protect the defendant and that the
destroyed material clearly implicated the defendant
• Anything missing is also construed to cover up
errors
• Tampering with records after the plaintiff has
copies is indefensible
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Constructing the Written Record
 In
traditional medicine the medical record
is a continuous record with new sheets of
paper added as needed and the new entry
begins at the conclusion of the last one
 In this record note is made at the entry
point of forms, reports, etc., copies of
which are then entered in the proximate
area of the record
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Constructing the Written Record
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To use this in colleges, attention must be
made to entering data immediately into the
permanent record
If multiple people enter into the record this
may be difficult
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SOAP notes
 SOAP
is an acronym for Subjective,
Objective, Assessment, Plan
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Developed from problem-oriented style in an
attempt to standardize note-taking
 Subjective
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is info gathered from the patient
Complaints, hearsay, and impressions of the
patient by the note-writer
May include the following:
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SOAP Notes
• relevant medical history
• how the patient describes the mechanism of the
injury or illness
• if the patient heard any noises at the time of the
injury
• if the patient reports a loss of function
• descriptive terms of any pain or sensations
associated with the injury or illness
 Objective
is information obtained from
evaluations and tests that are reproducible
by others
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SOAP Notes
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Used to confirm things from the subjective
section
Includes vital signs, range of motion testing,
strength, reflexes, measures of edema,
ligamentous tests, pain on palpation, gait and
posture evaluation, and functional evaluation
Largest section of the note
 Assessment
is the writer’s professional
opinion of the problems to be dealt with
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SOAP Notes
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Includes both short-term and long-term goals
In follow-up evaluation this section is used to
chart progress toward achieving the goals
Justification of any unusual goals or
treatments is entered here
 Plan

is based on the goals
This is where the number of treatments is
proposed as well as the methods used in the
treatments
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SOAP Notes
 Advantages
to SOAP is the information is
logically presented, it doesn’t rely on
grammatical correctness, and it can be
completed quickly
 Disadvantage includes having to
understand a particular profession before
you can understand what that profession
is trying to do in a situation
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Documentation Standards
 Medicare
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Requires the record to be complete before
any reimbursement is paid
Largest 3rd party payer
Most other insurance companies have
adopted the Medicare standard
Medicare standards require 4 components,
medical necessity, skilled care, significant
progress, and reasonable intensity
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Documentation Standards
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Medically necessary means the service is
recognized as effective medical practice
Skilled care means the caregiver must have a
license, educational credentials, not just
anyone can give the service, the service must
be sophisticated and complex
Significant progress implies that the physician
and AT believe the treatment will result in
improvement within a normal period of time
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Documentation Standards
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Reasonable intensity defines the quantity and
quality of treatment over the course of the
rehabilitation
Medicare also requires someplace in the
documentation specific info about the
referring physician, initial evaluation, plan of
care, daily documentation (including change
of status), progress note (including change of
status), and discharge summary
Initial evaluation establishes the baseline from
which to gauge necessity for treatment and
change of status
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Documentation Standards
 Many
other professions have standards for
medical records
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Herbert identified 37 associations with
standards
APTA has standards for documenting initial
evaluation, plan of care, progress note, and
discharge planning for patients treated by PTs
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Electronic Medical Record
 The
use of PDAs has enabled expansion
of EMRs.
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Reduces mistakes
Allows timely updating of the patient’s file
Compliance with HIPAA standards through
password protection, data encryption, etc.
Assists in acquiring data to support evidenced
based practice issues
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Computers
 Swift
easy access to medical records
 Must be backed up daily at a secure offsite location
 There are canned programs for rehab
records
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Confidentiality
 HIPAA –
Health Insurance Portability and
Accountability Act
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Specifies who can share information without
the express written permission of the patient
Limited to those employed to care for the
patient at a specific site
Team physicians without contract are bound
by HIPPA and cannot discuss patient info with
an AT or coach without the consent of the
patient
Can make the physician a contract member of
team with no money changing hands
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Confidentiality
 FERPA –
Federal Education Right to
Privacy Act

Cannot disclose info about students without
their express permission outside of the closed
system of the institution
• Means you cannot post grades by SS number, give
out personal phone numbers or grades without
permission of the student
• Before FERPA your grades would have been
mailed home to your parents, even if you were
over 21 (now 18)
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Confidentiality
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BOC Standard 4 requires confidentiality of
medical records
Confidentiality, FERPA, and HIPPA concerns
mean no coach is allowed to view our medical
records without the permission of the athlete
Release of medical information must be signed
by the patient before information may be
released to professional teams
Once released, UT has not control over what the
pro team does with that record
Suits have happened over unauthorized release
of info to pro teams or the media
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