^{By Elizabeth Neil PhD, LAT, ATC}

Checklist Components: 

Directions: Please use the checklist provided to carefully review a patient’s complete medical record. This process is not suitable for evaluating a current injury being treated presently. For each item on the checklist, indicate whether it applies by selecting yes, no, or not applicable. Refer to the descriptions below each item to understand the criteria. To calculate the score, divide the total number of yes responses by the sum of yes and no responses.

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• MD/AT order with specific diagnosis, signed, and dated
• Medical history
• Medications listed
• Date of injury onset listed
• Patient’s specific functional limitations noted
• Patient’s previous level of function listed
• Patient’s societal role listed
• Patient’s goal(s) listed
• MD/ or AT work restrictions indicated
• MD or AT precautions listed
• Functional limitations measured (numbers)
• Work/task requirements described quantitatively
• Athletic training diagnosis
• Impairments related to functional limitations
• Prognoses
• Patient barriers listed, if applicable
• Assessment clearly demonstrates patient’s need for rehab
• Duration of visits
• Frequency of visits
• Intervention list
• Goals for every 2 to 3 weeks of rehab
• Goals are quantifiable/measures
• Goals create clear criteria for discharge
• Specific, functional task listed in every goal
• Time deadline for every goal
• Impairment addressed in every goal
• Goals relate specifically to plan of care/intervention
• Reasons why modality was performed is listed, if applicable
• Specific modality info listed, if applicable
• Interventions selected clearly demonstrated need for AT skills
• Interventions are nonroutine and nonrepetitive
• Evidence of skilled feedback with exercises presented
• Exercises that can be performed at home are given in home exercise programs
• Assessment states patient’s response to treatment specifically
• Goals are reassessed every 2-3 visits
• Plan lists specific ideas for next treatment
• Modifications to treatment plan are listed
• Communication with patient, MD, etc are documented
• Changes in work status/restrictions noted
• Pt/Family education noted at least every 2 visits
• Canceled and no show appointments listed with dates
• Visit number (actually attended) listed
• Date of visit
• Treatment time listed in minutes
• All entries signed and dated
• Total of billed treatments does not exceed treatment time
• All treatment time billed required skilled intervention
• Correct use of group therapy charges
• Discharge note included

Definitions: 

1. MD/AT order with specific diagnosis, signed, and dated: A specific diagnosis (including working or probable diagnosis), provider’s signature, and date of completion.
2. Medical history: Detailed information about medical information that would be pertinent to this injury. This should include all body systems, not only orthopedic conditions. 
3. Medications listed: Medications including prescription or OTC and any supplements. If none, this must be stated. 
4. Date of injury onset listed: When did the patient first get injured or note symptoms beginning for chronic conditions. 
5.  Patient’s specific functional limitations noted: What is the patient not able to do that they normally are able to do. 
6.  Patient’s previous level of function listed: The desired hope to return to following the treatment plan.
7. Patient’s societal role listed: Think of this within disablement models. What does the patient do? Enjoy? Identify as?
8.  MD/ or AT work restrictions indicated: What did the provider give as guidelines to work or sport
9.  MD or AT precautions listed: These are activities that the patient is permitted to do, but should be cautious about doing. 
10. Functional limitations measured (numbers): Specific examples of what the patient is not able to do measures in a way that could later be compared. 
11. Work/task requirements described quantitatively: Information about work, life, or sport that have specific guidelines and amounts listed. 
12. Athletic training diagnosis: What is the diagnosis, probable diagnosis, or list of differentials
13. Impairments related to functional limitations
14. Prognoses: Referring to when the patient may anticipate to return to normal function
15. Patient barriers listed, if applicable: What has the patient noted is a barrier to their healing.
16. Assessment clearly demonstrates a patient’s need for rehab: Findings on the exam that indicate the need for a skilled intervention.
17.  Duration of visits: How long was the patient seen during the visit in minutes
18. Frequency of visits: How often are you treating the patient
19.  Intervention list
20.  Patient’s goal(s) listed: Making sure each patient has at least 2-3 goals. This should include both long and short term goals. 
21.  Goals for every 2 to 3 weeks of rehab: Short-term goals for the care must be written and completed
22. Goals are quantifiable/measures: Each goal must have a specific way to ensure that the goal can be met.
23. Goals create clear criteria for discharge: The long-term goals must demonstrate when the patient is healthy enough to be done with care.
24. Specific, functional task listed in every goal: Details to know that the goal was met through a specific task the patient can complete
25. Time deadline for every goal: How long it should take the patient to get 
26.  Impairment addressed in every goal
27. Goals relate specifically to plan of care/intervention: Make sure the interventions you are doing 
28. Reasons why modality was performed is listed, if applicable: Include the justification for using a specific modality
29. Specific modality info listed, if applicable: This is the parameters, intensity, area of treatment, duration, etc. 
30.  Interventions selected clearly demonstrated need for AT skills: A skilled provider must help plan the return to function for the patient
31.  Interventions are nonroutine and nonrepetitive: Make sure that the interventions are not just the exact same every time and match up with the short-term and long-term goals
32.  Evidence of skilled feedback with exercises presented
33. Exercises that can be performed at home are given in home exercise programs: A copy of the HEP should be included in the patient’s documentation
34. Assessment states patient’s response to treatment specifically
35. Goals are reassessed every 2-3 visits: Short-term goals are written every 2-3 visits.
36. Plan lists specific ideas for next treatment
37. Modifications to treatment plan are listed: Changes happen! Make sure that they are listed out with the reason for the change.
38. Communication with patient, MD, etc are documented: All communication including verbal, written, and any electronic communication should be copied into the medical documentation
39. Changes in work status/restrictions noted: This can include sport, occupation, or other activities the patient is involved
40. Pt/Family education noted at least every 2 visits: Ensuring that education is written down and described. 
41. Canceled and no show appointments listed with dates: Noting when a patient does not come to treatment including canceled and no shows.
42. Visit number (actually attended) listed: Keep a running total of the number of times you have seen this patient for this condition.
43.  Date of visit: The actual date of the appointment.
44. Treatment time listed in minutes: Breakdown of each treatment component in the care.
45. All entries signed and dated: Each and every entry signed with credentials of the provider and when the note was completed. 
46. Discharge note included: This note must have data about where the patient 

If Billing:

• Total of billed treatments does not exceed treatment time: Add each treatment up and the number must be equal or lesser than the total treatment time.
• All treatment time billed required skilled intervention: Ensure the treatment time matches the billing requirements
•  Correct use of group therapy charges: Ensuring that when group therapy occurs, it is billed properly. 

CITATION: Neil ER, Welch Bacon CE, Kasamatsu T, Nottingham SL, Eberman LE. Adapted through a Delphi Panel Review from work within the following citation: Harrelson, Gary L., Greg Gardner, and Andrew P. Winterstein. Administrative topics in athletic training: Concepts to practice. SLACK Incorporated, 2009.