By Maria Hutsick
Maria Hutsick, MS, ATC, LATC, CSCS, is the Director of Sports Medicine at Boston University. She has also served on the NCAA Competitive Safeguards Committee and the NATA’s Board of Certification.
Training & Conditioning, 15.2, March 2005, http://www.momentummedia.com/articles/tc/tc1502/ontherecord.htm
Twenty-five years ago, record-keeping in athletic training was pretty simple. Here at Boston University, we used a recipe box and index cards. Each team had a section in the box, each injury was recorded on a card in SOAP note format, and daily treatments were recorded on the backside. That was it.
Today, documentation is a more complicated aspect of the athletic trainer’s job. Records should be very comprehensive and include outside medical services. We need to ensure our athletes’ files are kept private, and our record-keeping system must keep up with changing legal and insurance issues.
Over the past several years, as education reform has raised the stature of the athletic trainer within the medical community, there is an even greater responsibility to maintain complete records of all patients evaluated and treated, regardless of work setting. The recent push by the NATA to have Medicare programs recognize athletic trainers as an important part of allied health care has also raised the need for clear, concise record-keeping.
And most importantly, maintaining accurate records is a way to ensure a thorough and organized thought process for athlete care. On both a daily and long-term basis, these notes help provide a structure for thinking and problem solving.
How does the busy athletic trainer keep up with the new trends in record-keeping? How can you figure out the best system for your department? In this article, I’ll provide some suggestions based on upgrades we’ve been working on at Boston University.
REVIEWING YOUR SYSTEM
The first step to upgrading your record-keeping system is to thoroughly review your current system. This review should involve administrators outside the athletic training room, including your athletic director and legal counsel.
Athletic trainers need to be proactive with their administrators on many topics, but establishing, maintaining, or upgrading your institution’s medical record-keeping system should be near the top of the list. Medical records not only serve the practical purpose of documenting an organized plan of care, they are also the institution’s first line of legal defense in the case of a wrongful-injury lawsuit.
The questions you should answer, with help from athletic administrators and legal counsel, include:
• How in-depth should our records be? Explain your current system and ask if the notes you keep provide enough detail in case of a lawsuit.
• What is the length of time the athletes’ records must be retained? Most states require that medical records be retained for at least seven years.
• Will our record-keeping process stand a test in court? Ask your legal counsel to ascertain if a judge or "expert witness" might be able to find any flaws in the way your department keeps its records.
• Is the storage of our records adequate? To comply with HIPAA and FERPA regulations, printed records need to remain in locked file cabinets, ideally behind locked doors, and computer records need to have limited, password-only access. Discuss whether your system is secure enough.
The next step is to review your system with your athletic training staff. Some questions to consider include:
• What are our goals for record-keeping? Do we simply want to document our athletes’ daily treatments, or might we use these records to write case studies or conduct research?
• Does our system include clearly stated procedures?
• Does everyone who handles these files understand the correct procedure for writing and storing the records?
• Do our records provide the information needed for any kind of outside agency review, such as NCAA redshirt requests or insurance company inquiries?
• What type of technology do we have, or might we need, to improve our medical records?
Another worthwhile step in assessing the quality of your record-keeping system is to test it. A simple test is to compile the records from a significant injury that occurred one or two years ago and review them. Can a complete story be told? Do the records indicate the description of the injury, care provided, and dates of the progression back to full participation? If there was a question as to the efficacy of the treatment provided at any stage, would the records explain and justify the actions taken?
If your current record-keeping system satisfies legal and administrative needs, your next step is to evaluate the efficiency of the system. Is there technology that would reduce the amount of time athletic trainers spend keeping records? There are many computer software options for athletic training record-keeping, and some schools may choose to write their own software.
In many cases, the above reviews will lead to the realization that you may need more resources to help upgrade your system. This, of course, leads to another discussion with upper-level administrators.
How can you get more resources at a time of shrinking budgets? Pointing out the liability risks of poor record-keeping is a good place to start. But it’s also critical to educate your administrators about our ever-changing profession whenever a chance arises.
It’s a good idea to look for openings within specific situations. For example, several years ago, one of our coaches insisted that an athlete sustained an injury and requested a medical redshirt letter in order to add a year of eligibility for the athlete. We had no record of an injury for the athlete in question, and so the coach accused us of not keeping adequate records. It turned out the coach was trying to obtain the extra season due to the skill of the athlete and not because of a substantial injury. This incident opened up an opportunity to discuss with the athletic director our record-keeping system and how we might make it better.
Because of this incident and consequent discussion, I was provided funds to computerize our record-keeping system. I was given the okay to purchase the supplies and hire the computer support needed to implement a more in-depth and professional system, which we have been upgrading and revising ever since.
Another situation involved an athletic departmental review of staff job descriptions. Recently my administration requested that all athletic department heads re-write their staff’s job descriptions and break down percentages of how much time is generally spent on different job tasks. When I handed in my report, administrators were shocked at how much time my staff spends completing paper work. In response, they finally relented to my previous requests for the services of a secretary to help with record-keeping.
TYPES OF RECORDS
Once you have analyzed your current procedures and gotten feedback from athletic administrators, the next step is to discuss how you might want to upgrade your system. A good starting point is to simply categorize and make rules for the different types of records you keep. Here are some suggestions:
Evaluation & Treatment: Accurate medical records are your most important tools in legal defense. A case can be won or lost based on the detail, quality, and content of your records. Entries must fully describe the athlete’s history, your physical evaluation, all special tests, your assessment, treatment plan, referrals, and follow-up. Each entry should be clear, be concise, use medical terminology, and be dated and signed.
Physician Records: These may include office visit notes, post-operative notes, and clinical notes. If your physicians hold clinics in your facility, their notes must be transcribed and made part of the athletes’ records. All visits to off-campus physicians should be recorded on a separate sheet of notes and clearly define the reason for seeing the physician and the plan of care. Also, any special tests required or medical prescriptions must be recorded.
Medications: If your facility chooses to provide any medicine, either by prescription or over-the-counter, you need to keep a record of all drugs you have on the premises and when they are distributed. The drugs must be stored in a locked cabinet in individual dose packs clearly labeled with the drug’s name, directions, expiration date, and lot number. When they are administered, staff members must follow the legal requirements for disbursing them.
Insurance Records: The responsibility for insurance claims will vary from one institution to another depending on what procedures are used and if your facility is a high school, boarding school, college/university, or professional sports organization. The athletic trainer should be the initiator of the insurance claim, but the administration of the claim should then be handed off to someone in your business office who is trained to handle insurance.
Clearance To Play: For an athlete to participate in athletics at any level, a physician’s clearance must be kept on file. We ask each incoming athlete’s primary care physician to sign underneath a statement that says: "I, the undersigned health care provider, find this student-athlete physically able to participate in highly competitive intercollegiate athletics." When athletes arrives on campus with their forms, they are further screened by both our general medicine and orthopedic physicians. If all is in order, they are cleared to participate.
Once you have formulated rules for all the types of records you keep, you can start looking at how to refine the system at your particular setting. Here at Boston University, we began upgrading our record-keeping system about 10 years ago. The system evolved with the help of our academic program director, assisted by some experts in computer programming.
Our first upgrade was to our hard-copy files. We purchased a lateral file cabinet, which is kept in our office area. The office is locked and the facility is locked so a double-lock system is in place. Only authorized personnel have access to these records, and the files only leave the cabinet to be updated by staff.
Each athlete has one file folder. Each team is assigned a specific color so its athletes’ records can be found quickly in the lateral file cabinet. A medical tab system identifies each athlete by last name.
Each athlete’s record is divided into sections. The front of the folder, along with having the athlete’s name, has his or her date of birth, student identification number, and year of graduation. We place a sticker on the outside if they have an HMO or allergies to any medications. A bar code sticker is also placed on the front of the folder, which works with our scanner medication inventory system. Each time an athlete is prescribed a medication by our physicians, all information is scanned into the system.
Inside the folder, on the left side, we place the athlete’s medical history booklet. This includes the dates of each orthopedic and general medicine pre-participation screening exam, demographic information on insurance, emergency contact, and a place for the athlete to verify that the information is true and accurate. There is a consent to treat, medical information release, and informed consent and waiver of claim form. These forms must be signed and dated. If the athlete is under 18, his or her parents must also sign them. The booklet also includes an in-depth medical history for illness, joint injury, and each body part. The last page includes shot records and clearance to play signatures.
All orthopedic and general medicine clinic records and dictation are also placed in the left side of the folder. Our physicians conduct on-site clinics during the week and dictate their records via phone to a medical transcription office. These dictation records are e-mailed back to us and placed in the athletes’ files. They are also color-coded: General medicine is printed on pink paper and orthopedic on green paper.
The middle pages of the folder have post-op notes and any MRI, X-ray, or other diagnostic reports. The back of the middle pages have insurance records and referrals. Each time an athlete is sent to an outside health care provider that charges a fee for service, our computer generates a claim form with referral information, insurance information, and the name and address of the treatment provider. The claim form requires the athletic trainer’s signature. A business office staff person follows up on insurance claims and works with parents and athletes to expedite insurance claim processing.
The inside right side of the folder is where the treatment notes are kept. These are SOAP notes, progress notes, and records of phone conversations with insurance companies, parents, and health care providers. Medical release forms are also kept here.
All athletic training students and staff must sign and date each entry in the record. All student entries must be reviewed and signed by the supervising athletic trainer.
The system works well. However, in more recent years, we have found ourselves drowning in a sea of paperwork with all this record-keeping. Therefore, our next step was computerizing some of our records. One of my assistants is very computer savvy and he was able to write a program that fits our needs. This is the database that we use for insurance, and a comprehensive record. He continues to update our database and refine it on a yearly basis.
ENTER THE COMPUTER
We have begun computerizing our records with our insurance and referrals paperwork. Our database allows us to print an initial insurance claim form, a referral form, and any of the X-ray, MRI, or bone scan forms that our radiography services require. The data is entered into the athlete’s record and the software automatically files information where it is needed.
We have several desktop computers and each staff person also has a laptop and PDA. We can download our team files onto the PDA and have all insurance and injury data for that team on hand when we travel, as well as access to the Internet and scheduling information. We will eventually upgrade to BlackBerry® devices so we will have a phone, e-mail, and all the rest in one tool that eliminates the need to carry a laptop, PDA, and cell phone.
We are currently working with a computer expert to write a program that will allow us to send compliance and injury reports, compile statistics for research, insurance needs and forms, and maintain an injury tracking database, with SOAP notes and ongoing treatment notes. We will also be able to download any teams’ insurance and emergency contact information on our PDAs and carry them with us on away trips.
Next, we will incorporate an interactive Web site, which will allow our student-athletes and parents to complete most of their medical history online. It will be a password-protected program that students will access. Forms that need a signature will be downloadable with easy printing.
Our system is in transition and we will continue working to streamline as much of the paperwork as possible. We hope to eventually have all of our injuries entered in to the database so we can track injury trends, write case studies, and conduct research projects. The only staff person who is doing this now is our men’s ice hockey athletic trainer, who has a separate athletic training room and was able to upgrade more quickly.
Of course, all the systems in the world won’t work unless your staff is committed to using them. Thus, the director of sports medicine should conduct a yearly review on the proper way to document the care of athletes at the facility. There must also be formal instruction for all physicians, administrative staff, and students on how to use the medical record-keeping system.
If your facility utilizes athletic training students, they must be instructed in the proper recording of your medical record-keeping system and all notes must be signed by their supervising athletic trainer. If your department uses clerical help, a non-disclosure agreement should be signed and on file.
We are fortunate at Boston University to have a highly motivated and professional staff that practices a high level of care. Even though each staff member is responsible for specific athletic teams, we all see walk-ins at the athletic training facility. Therefore, each of us knows our notes may be read by others on staff.
Every Monday morning we have a staff meeting and one of the topics we discuss is called the "Hit Parade." The Hit Parade is a list of all injured athletes who require follow-up care. We go over each one, discuss what needs to be done, and assign someone to do it. This way, teams that don’t have an athletic trainer assigned to cover their practices will not be neglected.
The clinical staff and the academic staff work very well together to educate our athletic training students. The students are taught the proper way to perform medical record-keeping and must practice and have regular cognitive and psychomotor skills development (CPSDs) check-offs that are specific to our record-keeping system. The students are graded on these skills and each staff person is assigned to supervise several students. The staff must co-sign any notes that the students enter into the record.
A good record-keeping system can protect you and help in your organizational plan for your facility. Assess your needs, review your current system, and talk to others in the field about how you can make your record-keeping system the best it can be.
The author would like to thank Jon Almquist, ATC, for his help and feedback on this article.
Sidebar: DO’S AND DON’TS
A medical record should "tell the story" of the athlete, allowing other health care providers to quickly read and understand the athlete’s past and current health conditions. Each medical record is a legal document that protects both the health care provider and the athlete.
The following general guidelines should be kept in mind when compiling medical records:
• Be certain that your entries are clear and readable.
• Don’t squeeze words into a line or leave blank spaces.
• Draw a line through all blank spaces after each entry.
• Never erase, write over, or try to ink out a record. If you make a mistake, draw a single line through the mistake with the date and your initials in the margin.
• Use only standardized medical abbreviations.
• Date and sign each entry made in the record.
• Use a full signature when signing notes.
• Always note when and by whom medical records are photocopied.
• Require athletes to sign a medical release when sharing their record with anyone.
• Use specific language and avoid generalizations and lengthy descriptions.
• Document athletes’ statements verbatim. For example: The athlete states, "I heard a pop when I landed on my knee."
• Record all instructions, including limitations, restrictions, and follow-ups.
Sidebar: CHECKING IT TWICE
The following is a list of questions you can ask yourself when reviewing your record-keeping procedures.
Organization of the Record
1. Is there an internal organization of the charts in the athlete’s file?
2. Is there a systematic filing of medical records?
3. Are medical records individualized by athlete name or ID number?
4. Is there is a place for demographics in the medical records?
5. Are pages and forms secure in the files?
6. Is there a signed consent to treat form?
7. Is there a signed medical information release form?
8. Is there a medical history that includes shot records and is signed by the family physician and athlete?
1. Are confidentiality rules in place? Do all staff members who handle medical records sign a confidentiality statement?
2. Are there policies and procedures in place regarding the release of information?
3. Are medical records stored in a secure manner away from unauthorized access?
1. Do all entries contain author identification?
2. Are all entries dated?
3. Are all entries legible?
4. Are record-keeping practices and procedures reviewed yearly?