Chapter 3. Injury Record Keeping

1. Chapter 3. Injury Record Keeping

2. Injury Record Keeping Accurate and detailed record keeping is a mandatory part of any athletic program.

3. Why Keep Records? • Communication and quality control • Legal considerations • Research • Injury history • Traffic patterns

4. Communication and Quality Control • This is by far the most important reason for keeping records.

5. Communication and Quality Control (cont.) With . . . Self Others involved in the case, and Athlete

6. Communication with Self • It is hard to keep all the details of individual cases straight without written records. • A periodic review of cases helps you see progress. • A review may stimulate ideas for improved treatment.

7. Communication with Others • All members of the team should know what the others have done, creating continuity. • Without records, the efforts of each will be isolated rather than being part of a coordinated whole. • It is confusing to an athlete to get conflicting advice about his or her problem. (Used with permissionfrom Castel D.International Academy of PhysioTherapeutics. Clip art.)

8. Communication with Others (cont.) • A physician’s efforts are often more efficacious if he or she receives detailed information.

9. Communication with Athlete • Keeps athlete honest—that is, makes the athlete more compliant with rehabilitation program.

10. Legal Considerations • The value of a document depends on its accuracy and detail. • Most lawsuits occur years after the event, usually after the memory of specific details is gone. • Written records supply memory.

11. Research • To provide memory so you can compare efficacy of treatments • Thus improve methods

12. History • Specific and detailed information is important to a variety of people: • Insurance company • College and professional recruiters • Military • Some employers • Need for information often occurs months after the injury occurred

13. Traffic Patterns • Establish daily, weekly, monthly, and yearly traffic patterns. • Such records can be the clincher in verifying the need for additional facilities and/or staff or in preventing cuts in the program.

14. What Records Should Be Kept • Medical information • Incoming student athlete • Returning student athlete • Injury evaluation

15. What Records Should Be Kept (cont.) • 1. Evaluation of Injuries • a. Athletic injury report form 2. Treatment of Injuries a. Daily treatment log b. Individual treatment sheet c. Daily weight-recording form

16. What Records Should Be Kept (cont.) 3. Referrals to and from others a. Medical referral b. Rehabilitation referral 4. Medical Information a. Incoming student athlete b. Returning student athlete

17. What Records Should Be Kept (cont.) • 5. Equipment Upkeep • a. Ultrasound calibration • b. E-stim maintenance • c. GFI check • d. Weight equipment maintenance

18. Initialing Forms • Every entry should be initialed by the person making the entry. • This lets people know who to go to for additional information.

19. SOAP Notes SOAPis an acronym; each letter represents a section of the patient note.

20. SOAP Notes (cont.) S: Subjective ► Information gathered primarily from questioning the athlete about his or her present condition Example: “I twisted my ankle, and it hurts right here.”

21. SOAP Notes (cont.) O: Objective ► Reproducible information the athletic trainer gathers through tests or other evaluative measures Examples: laxity stress tests, girth, volumetric tests, ROM

22. SOAP Notes (cont.) A: Assessment ► Clinician’s professional judgment or impression of the injury Example: second-degree inversion ankle sprain

23. SOAP Notes (cont.) P: Plan ► Course of action that the athletic trainer and the patient will take to treat and rehabilitate the injury; includes both short- and long-term goals