Appropriate Documentation in Athletic Training
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March 29, 2018
By Nicole T. Wasylyk, MSEd, LAT, ATC
Documentation in the healthcare industry is of utmost importance in providing high quality, safe care to our patients. For billable providers, documentation becomes a crucial component to reimbursement. As athletic training billing increases, the documentation of services will be important; however, we must not lose sight of the importance of documentation for patient care purposes. Best practice guidelines are available through the National Athletic Trainer’s Association (NATA) website.1 The best practice guidelines for athletic training documentation outlines the importance of medical documentation, reviews pertinent terminology regarding documenting, discusses state and federal laws as well as considerations for electronic documentation and communication.
There are many documentation systems commercially available within the medical field with a wide range of costs. As a result, there are potential barriers to documentation depending upon the practice setting. A large, academic or medical based institution may have an electronic health record (EHR) system at their disposal while a small, rural high school may not; a barrier is often cost. Small institutions may not be able to afford such a system. Even if an EHR system is unavailable, documentation standards remain the same. Documentation should be legible and in pen (not erasable pen or pencil). Although, often times, individuals will state that documentation should occur in black ink only, both black and blue are acceptable. Colors other than black/blue can be difficult to read if photocopied or faxed. Paper and pen documentation should follow similar guidelines for electronic documentation to include:
- Appropriate medical terminology use
- Timeliness in documentation
- Accurate documentation of evaluation, plan and/or treatment performed
- Safe storage of the information
It is crucial to store this information in a safe location and restrict access to only those directly involved in the patients’ care or those who have obtained informed consent from the patient. A safe location in this regard is defined as a cabinet or drawer than can be locked for secure access only. Simply storing the documents in an open room is unacceptable and could put the information at risk for patient privacy violations. Information should not be stored on an unencrypted system such as Google Docs, home computers or left unattended in an open area where it can be easily seen.
Documentation of a patient encounter should be clear, concise and accurate. Use of appropriate medical terminology is important to accurately describe the condition, treatment plan and treatments performed. Medical abbreviations should be limited and should be kept to commonly accepted abbreviations.2 Creating unique short hand, especially on paper documentation, can lead to errors with interpretation and understanding of the abbreviation. The commonly accepted documentation format should include the following sections: subjective, objective evaluation, assessment and plan.3,4 Depending upon the practice setting or EHR system, more information may be required such as past medical or surgical history and current medications or allergies.
Documentation should ideally occur during or immediately after a patient is seen to ensure accuracy as well as the ability to communicate with other healthcare professionals in a timely fashion. There may be multiple healthcare providers involved in the care of a patient, ensuring documentation is completed and communicated to the team in the appropriate manner can assist in improving the quality of patient care.
Communication and Protection of Health Information
The Health Insurance Portability and Accountability Act (HIPAA),5 aims to protect individuals’ personal health information (PHI) while allowing for the safe exchange of this information between providers and facilities to promote high quality healthcare.6 PHI can be defined as a patient’s past, present or further mental/physical health and can include, for example, an individual’s name, date of birth, medical record numbers, lab and/or radiology reports. The HIPAA act includes regulation over all formats of PHI; electronic, paper and verbal. It is important to consider how we share patient information, especially as the ease of communication increases. Text messaging and unencrypted emailing of PHI are inappropriate forms of communication as they are not secure methods. Secure email, fax, verbal or approved EHR communication are appropriate formats for communicating PHI. Informed consent is also a critical part of both patient care and communication. Best judgement should be exercised when opting to share patient information as it may require written informed consent.
Reimbursement from third party payers for services rendered by an Athletic Trainer remains a complex issue. As a result, documentation and coding requirements for these services is also multifactorial. For those interested in documentation requirements pertaining to reimbursement resources are available through the NATA, and likely state associations. The billing and coding department of the clinic or hospital based organization where reimbursement will take place should also be utilized as a resource.
How to select an EHR: https://www.nata.org/sites/default/files/how-to-select-electronic-medical-record-system.pdf
CORE-AT Electronic Medical Record (free EHR system): http://www.coreat.org/electronic-medical-record.html
Billing, Reimbursement, and CPT codes: https://www.nata.org/practice-patient-care/revenue...
1,3. Best Practice Guidelines for Athletic Training Documentation. https://www.nata.org/sites/default/files/best-practice-guidelines-for-athletic-training-documentation.pdf. Published September 17, 2017.
2. Parvaiz MA, Subramanian A, Kendall NS. The use of abbreviations in medical records in a multidisciplinary world – an imminent disaster. Commun Med. 2008;5(1):25-33. https://www.ncbi.nlm.nih.gov/pubmed/19363877
4. Documentation and Coding Guidelines for Ahletic Trainers. https://www.nata.org/sites/default/files/Documentation-and-Coding-Guidelines-2011.pdf. 2011.
5.Health Insurance Portability and Accountability Act of 1996. Pub. L. 104-191. August 21, 1996.
6. HIPAA Basics for Providers. https://www.hhs.gov/sites/default/files/privacysum...
About the Author
Nicole Wasylyk works as an Athletic Trainer in a physician practice at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire. Prior to DHMC she resided in Madison, Wisconsin and was an Athletic Trainer in a physician practice at Meriter-Unity Point Health. Wasylyk obtained her Bachelor of Science in Athletic Training from Boston University and Masters of Science in Education from Old Dominion University. She has completed a residency program for healthcare providers who extend the services of a physician at UW Health. Wasylyk also obtained her orthopedic technician certification. Her professional interests include injury surveillance and prevention, standardization of best practices and patient reported outcomes collection.