1
Q
Why document
A
- legal protection
- memory aid
- legal requirements
- professional standards
- insurance requirements
2
Q
two kinds of information
A
- medical records
- program administration records
3
Q
Medical records
A
- physical examination forms
- injury eval/treatment forms
- referral form
- emergency information
- permission to treat
4
Q
Reports of special procedures
A
- strength testing
- blood tests
- UA
- x-reays/imaging
- reports
- surgical reports
- cardiac assesments
5
Q
Program administration records
A
- injury report for coaches
- budget information
- nonmusical correspondence
- equipment and supply information
- personnel information
- reporting information
- pt and student education materials
6
Q
medical record guidelines
A
- must be legible
- use permanent ink
- identify time, date on every entry
- sign each record
- describe findings objectively
- do not erase errors
7
Q
Guidelines
A
- write asap after care is given
- be factual and specific
- use pt. quotes
- chart only the care you provided
8
Q
Records storage
A
- easily accessible
- centralized: carbonless copy
- electric record-keeping
- must be stored securely
9
Q
Physical Exam form
A
- should be first in the medical record
- includes: personal data, past mdhx, vital signs, functional tests
10
Q
Five methods for documenting injury evaluation and treatment data
A
- problem oriented medical record
- focus charting
- charting by exception
- computerized documentation
- narrative charting
11
Q
Referral form
A
- provides legal proof the AT consulted with a physician as required
- athlete’s name, sport , injury date etc
- HIPAA compliance
12
Q
Emergency information
A
- easily accessible
- include insurance information
- travel
13
Q
Permission for medical treatment
A
- legal principle that individuals must consent to medical treatment
- maintained in medical record
- especially important in high school
14
Q
Release of medical information
A
- health care provider cannot release medical information with consent of the patient
- FERPA: edu records students do not have the legal right under FERPA to access their medical records
- HIPAA: in general, an AT works in environments subject to HIPAA rules
- we work under hipaa
15
Q
HIPAA
A
- obtain consent for treatment “notice of privacy practices”
- obtain authorization to release health information
- safe guard pt information
- release only the minimum necessary information
16
Q
Insurance information
A
- not part of a medical record
- different purposes and uses; confidentiality laws protect them in different ways
- do not put medical records supporting an insurance claim in the insurance folder
17
Q
Program Administration records
A
- more general than medical records and relate to the functioning of an athletic training program
- standards for confidentiality generally less than medical records
- maintain confidentiality
18
Q
Coach report
A
- daily written report of the health status of their athletes
- improves communication
- document recommendations for participation status
- confidentiality
19
Q
Program administration records
A
- budget information
- nonmusical correspondence
- equipment and supply information
- reporting information
- patient and student education information
20
Q
Filing medical records
A
- important to have an effective and appropriate system
- different settings require different filing systems
- medical and personnel records should be stored in a separate, locked cabinet
- 7 to 10 years
21
Q
Recommendations
A
- master outline of files in the entire system
- file labels
- do not overfill each file
- organize material in each file chronologically or alphabetically
Administration
flashcards
Decks in class (5)
# Cards
