Jan 29, 2015For the Record
From helping you lobby for more resources to protecting your program against lawsuits, a top-notch medical record keeping system offers many benefits. Does yours?
By Jon Almquist
Jon Almquist, ATC, is the Athletic Training Administrator for Fairfax County (Va.) Public Schools. He can be reached at: [email protected].
Think back to your days in an athletic training education or internship program, and try to remember what you were taught about note taking and record keeping. When I was a student almost 30 years ago, this meant learning how to take SOAP notes (subjective, objective, assessment, and plan) and using the HOPS format (history, observation, palpation, special tests), and many from my generation probably remember the same. To this day, SOAP and HOPS continue to be part of the curriculum approved by the Commission on Accreditation of Athletic Training Education, and for some programs, thatís where information management begins and ends.
Athletic trainers have widely varying opinions on record keeping. Some consider it a necessary evil or a “required waste of time,” adding to our already daunting workload and taking time away from the treatment of athletes. Others acknowledge its importance, but don’t agree on exactly what information should be kept, how to accomplish the task most efficiently, or how to use the data gathered over time. And some have embraced it wholeheartedly, implementing elaborate computer-based record systems or home-grown database programs, “syncing” them with handheld devices for instant updates, and finding ways to synthesize all the information into monthly, quarterly, or annual reports detailing everything from man-hours to injury rates to how much they spent on supplies.
In my own setting as the Athletic Training Administrator for a public school system, we have made record keeping a priority, and it has paid off for us in several ways. In this article, I’ll outline the benefits of a complete and well-organized information management system, and explain how it has helped us improve the care we provide for athletes every day.
WHY IT MATTERS
There are some key reasons why certified athletic trainers should document every action we perform within our scope of practice. The most basic is that if we want to be considered credible healthcare professionals, we must acknowledge that thorough record keeping is the standard of practice in today’s medical world. Everyone from physicians to physical therapists to dentists maintains complete records of their evaluations and treatments, and athletic trainers should be no exception.
There are other crucial reasons for record keeping as well. They include all of the following:
Legal liability. If an athlete feels they were not treated correctly, they or their parents need only pick up a phone and call an attorney to begin a sequence of events that can make any athletic trainer miserable. Anyone who has been on the receiving end of a lawsuit will tell you that accurate and complete records are the best defense. If you have documentation showing what happened each time the athlete was under your care, proving you acted appropriately is as simple as finding the right folder or computer files.
Without complete records, it is your word against the athlete’s, and key details of past treatments can be difficult to nail down. If your records don’t “tell a story” from the initial evaluation through the release to participate without restriction, you could be taking a serious risk if someone ever questions what you did.
Our school system has been contacted several times by attorneys’ offices to inquire about an athlete’s treatment. When lawyers are deciding whether to file suit, they first investigate the extent of an athlete’s injury, what our obligation was to provide a certain level of care, and whether there was any breach of that duty. By being able to review our files and say, “Our written records show that the chain of events was X, Y, and Z,” I’m sure we have nipped several potential lawsuits in the bud.
Communication. Anyone who works in high school or college athletics is familiar with the potential for miscommunication between athletic trainer and athlete, athlete and parent, athlete and coach, athletic trainer and parent, and so on. A good record keeping system can streamline the sharing of information, help prevent miscommunications, and resolve problems more quickly when they occur.
For instance, a parent may contact the school with concerns about how their child was treated. Maybe they received incomplete information from a coach, or their son or daughter left out some key details when describing what happened. If you can say definitively that the athlete was given certain directions, or that messages were left on the voicemails of two phone numbers in an attempt to contact the parent, their attitude often does a complete 180.
Parents today want to take a more active role in their children’s activities, especially in matters of health and safety. With the proliferation of cell phones and e-mail, athletic trainers must be prepared to maintain a higher level of communication, and to thoroughly document what athletes and their parents have been told.
Proof of worth. In the high school setting, some administrators still think of certified athletic trainers as a luxury. In college, many departments are understaffed and not given all the resources they need. The best way to correct these problems is to have a comprehensive record of all the ways athletic trainers add value to an athletic program.
Keeping excellent records allows you to generate detailed reports for administrators and school boards illustrating the true impact athletic training has on the student body. For example, Fairfax County Public Schools is now the 12th largest school system in the nation, with over 170,000 students. Each of our 25 high schools has two certified athletic trainers (one full-time and one associate who also teaches). Our record keeping system allowed us to complete a recent analysis showing that our football players alone suffered a total of 24,207 injuries and 4,276 time-loss injuries over one five-year span, for an average of 3.93 injuries per 1,000 athlete exposures.
Whenever resources are being allocated, putting hard data like this in the hands of decision makers presents a much more compelling case than anecdotes, testimonials, and complaints of being understaffed. A professional summary of athletic training activities can also help you advocate for new equipment or a larger facility. Even administrators who don’t view athletics as a top priority can be convinced when they see that treatment from on-site athletic trainers reduces classroom time missed by student-athletes.
Finally, analysis of your injury data can help you set priorities in the athletic training services you provide. A spike in ACL injuries among your female basketball players might spur you to talk to the coach about adding preventive exercises to their warmup routine. Or a sudden drop in lower-body injuries on your football team might validate the new ground-based training program the strength coach is using. The possibilities for putting the data to use are endless.
WHAT TO RECORD & HOW
Here’s the simplest possible summary of what thorough record keeping really means for today’s athletic trainers: Every problem or injury that’s brought to your attention should be represented in your files by its own record, containing information about the initial evaluation, the mechanism of injury and any pre-existing or contributing factors, and what treatments and other interventions were provided to resolve the situation. For problems or injuries that require more than a one-time intervention, the record should document all evaluations, treatments, and progress made until the return to full function.
Sounds simple enough, right? But if you tried following the above guidelines without some careful front-end planning, you’d quickly find yourself spending most of your day taking notes or sitting at your computer. Before long, you’d adjust by taking briefer notes, or perhaps limiting your records only to injuries that result in time loss. But this shortcut leaves you vulnerable–if what at first seemed like a minor injury or condition takes a turn for the worse, you’re already behind in your records and some pertinent information about early symptoms and treatments has been lost.
Clearly, one of the biggest keys to effective record keeping is finding a way to fit it into your daily tasks and schedule efficiently. I’ve found that a computerized record management program is by far the easiest solution for achieving this goal. Whether you purchase a software package dedicated to medical record keeping or develop your own database or spreadsheet-based system, given the many advantages, there’s no reason to not be using a computer to manage your records.
Computer-based electronic medical record (EMR) systems usually include point-and-click options with drop-down menus, which make it easier to create consistent records because you use the same format to input data for each entry. Most systems also have note fields where narratives and comments can be added as needed.
Drop-down menus make up the foundation of some computer systems, and they’re a great way to ensure that entries are uniform and thus can be used to compile trend data. The menus are often very detailed, covering everything from clinical impressions and mechanisms of injury to amount of pain reported by the athlete and various treatment options. Based on the selections you make from the menus, a program will create reports with summaries of injuries and injury rates, types of injuries sustained most frequently by sport, average number of treatments provided per injury or type of injury, and so on.
If you have a computer-based system, some simple logistics planning can make it as user-friendly as possible. For instance, at our schools we’ve found it very helpful to set up a computer right in the athletic training facility, with the keyboard and mouse at countertop height. This allows easy access for entering information, so it often takes as little as 10 or 20 seconds to record routine treatments. Our athletic trainers can even fill out some parts of the form as the athlete answers questions. We’ve learned from experience that if the only available computers are at desks with chairs, there’s a tendency to wait until “after the rush” to input information–and in the interim, important details can be forgotten.
Simple ongoing treatments, such as the application of special pads or routine taping and bracing, need just a short note in the athlete’s file stating what was done, when, and any relevant context information (for instance, whether a treatment was provided before or after practice). Re-evaluations of existing injuries, such as when you’re determining an injured athlete’s participation status, should take a minute or two as you provide notes on the evaluation results, injury progress, and new status. Evaluations of new injuries generally take the most time to document, so you may find it’s best to take brief (but detailed) notes during or immediately after your time with the athlete, and write up a full account later on when you’re less busy.
Some athletic trainers have found that documenting everything right as it happens is the best way to ensure the records leave no holes. This method, known as real-time record keeping, can help improve accuracy, but it does force athletes to wait as you complete notes from the previous patient. Others take a break to update their files after every two or three athletes they treat. However you decide to structure your record keeping schedule, remember that the shorter the time between when treatment is provided and when it is recorded, the better.
IN MY SETTING
When I started at Fairfax County Public Schools in 1983, I was one of the first people hired through a school board initiative aimed at bringing in certified athletic trainers for each of the 23 high schools we had at the time. We were full-time teachers who received a stipend to provide athletic training services after school hours. As it became evident that one athletic trainer per school was not enough, we added an associate position for each school in the late ’80s.
Back then, we compiled injury stats using data from our paper-and-pencil records, and we used those stats to develop an event coverage policy based on each sport’s injury frequency and severity. Our policy was often challenged by administrators who would see one injury in a low-risk sport and instantly decide it should be a higher priority. The statistics we had compiled helped us defend our policy, but doing so was very time- and labor-intensive.
In 1997, we began using a computer-based EMR program. Each school compiled its own data, and uploaded the information to our Sports Injury Monitoring System (SIMS) for district-wide analysis. This was a huge leap forward in making our information management more effective and less burdensome, and before long, we were putting the results to use.
In 2001, we had 24 high schools and the two athletic trainers at each school both had teaching responsibilities. We proposed converting one position for each campus to full-time athletic trainer with no teaching duties–something we definitely needed, but which carried a $1.3 million price tag. Thanks to our record keeping system, we were able to lay out concrete facts to support our proposal.
We noted that student-athletes in our system incurred over 3,800 time-loss injuries and 8,100 minor injuries per year based on data collected over a three-year period. We also explained that our athletic trainers conducted more than 82,000 treatments and rehab sessions over that time span, a figure that clearly demonstrated the need for a full-time athletic healthcare provider.
That first attempt didn’t succeed, but we kept compiling the data and presenting more and more facts and figures documenting the athletic training workload. Finally, in 2005, the restructured athletic trainer position was funded and implemented. That taught us two key lessons: Don’t give up, and use all available data to your advantage when making your case.
You didn’t become an athletic trainer because of your love for spreadsheets, medical note taking, or software programs that analyze trend data. But I have learned through experience that in athletic training, the old axiom “information is power” is truer today than ever. Excellent record keeping takes time, but with so many benefits, it’s definitely a wise investment.