What Is The Importance Of Keeping Proper Documentation Of Athletes’ Health Records?

Athletic trainers (ATs) are a part of the health care team and they provide patient care services under the direction of a physician, in accordance with their education and training, state statutes, and rules and regulations. Services provided by athletic trainers (ATs) include injury/illness prevention, education/wellness promotion, emergency care, examination and clinical diagnosis, therapeutic intervention and rehabilitation.

Injury and illness prevention along with wellness is a major aspect of ATs’ duties. They use EMR systems to provide accurate, up-to-date, and complete information about patients at the point of care and to get quick access to patient records for more coordinated and efficient care. For accurate transcripts of any recordings and dictation, they can rely on established sports medicine transcription services. Athletic training services provided for each and every medical situation need to be documented for diverse purposes.

Importance Of Proper Documentation Of Athletes’ Health Records

Accurate and up-to-date athletes’ medical records documentation

• facilitates better patient management
• helps with better continuity of care
• provides a precise narrative of services to help clinicians recall events at a later date
• helps comply with medical industry standards and statutory regulations
• provides a complete, accurate and timely record of a patient’s complete medical history
• facilitates communication and ensures a consistent level of care among and within multiple care-givers across various settings
• minimizes the risk of malpractice for ATs
• ensures legal protection
• provides a record of an initial evaluation of a condition, treatments and interventions
• helps to submit clear claims and get reimbursement on-time

What Should Be Documented By The Athletic Trainer?

Athletic trainers document –

Accident and Injury Reports

• athlete’s demographic details, name and age
• date of injury, date of the report
• specific body part that is injured
• information about how the injury or accident occurred
• whether the injury is a new or previous one
• AT’s thoughts about the injury

Treatment Records

Any treatment an athlete received such as –

• ice or heat application, elastic wraps
• stretching, strengthening
• splinting, or medical referral

Rehabilitation Charts

• injury assessment
• recommended rehabilitation programs
• exact treatment received by the athlete and the date
• problems or complaints or any changes in treatment
• athlete’s response to treatment and re-evaluation data

Any Patient Encounter

• any interaction with a patient when providing athletic training services
• written, verbal, or electronic communication with any individual or entity

ATs also use diverse injury-tracking systems such as Athletic Trainer System (ATS), SportsWare, Sports Injury Monitoring System (SIMS), SimTrack, NCAA, and Presagia Sports that store and provide valuable information such as demographics, injury report, progress notes, medication log, insurance information, exercise flow sheet and more.

EMR systems help to promote accurate and complete documentation, and secure sharing of electronic information with patients or other clinicians. They enhance privacy and security of patient data at the same time. ATs can consider benefiting from EHR-integrated transcription services from reliable U.S. based medical transcription companies. The National Athletic Trainers’ Association (NATA) recommends ATs to be aware of the documentation needs specific to their setting and comply with all state regulations, established guidelines, and institutional requirements/expectations.