The Importance of Medical Documentation

By Elizabeth Neil PhD, LAT, ATC
You might be thinking, “Oh great, a blog on medical documentation.” Let me start by acknowledging that medical documentation isn’t the most exciting topic for many. Athletic trainers are busy, and medical documentation is often the last thing on their minds. When I ask ATs why they document, the common response is often “CYA”. However, in teaching about the Importance of Medical Documentation to athletic training students, I categorize it into two main reasons: (1) patient care and (2) legal implications.
I intentionally prioritize patient care as the primary reason for documentation. Why? The National Academy of Medicine (formerly the Institute of Medicine) defines patient-centered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, ensuring that patient values guide all clinical decisions.”
This approach necessitates a genuine partnership between individuals and their healthcare providers. I challenge students, colleagues, and myself to integrate medical documentation as an integral part of patient care rather than an additional task, believing that this shift in perspective will lead to positive changes in habits and attitudes.
Legal Protection Guidelines: It is still important to be aware of the legal protections governing medical records, which vary based on patient population, employer, and documentation type:
- HIPAA: The Health Insurance Portability and Accountability Act of 1996 more commonly known as HIPAA. This act is the original protection over patient’s health information. Here is a link to the 18 identifiers of HIPAA as a reminder that you are abiding by patient protection principles.
- FERPA: Family Educational Rights and Privacy Act of 1974 is a federal law that governs the access to educational information and records through publicly funded educational institutions.
- HITECH: The Health Information Technology for Economic and Clinical Health Act provides additional protections related to health information technology.
How and When to Document?
So, how do I begin? The NATA Best Practice Guidelines for Medical Documentation are a great place to start! Here are a few definitions that will help guide our conversation on the Importance of Medical Documentation.
Patient Encounter: “A patient encounter is defined here as any interaction with a patient when an athletic training service is provided or a communication occurs regarding their health status. Communication regarding a patient’s status may include, but is not limited to, written, verbal, or electronic communication with any individual or entity.”
Change in Patient Status: Any unexpected changes or deviations from the expected result should be documented in the interim and include appropriate follow-up documentation. When an AT provides any service, evaluation, consultation, subjective and/or objective measurement of a status change, the specifics of the service provided or action taken, and the short/long-term plan would need to be documented.
TLDR: Each and every time that you speak to a patient for medical care or provide any care you need to document!
As we approach summer, many of you will be working per diem shifts and camps. Here are practical tips to streamline your documentation process. You might think, “Okay Beth, you work in academia and might have forgotten what it’s like.” In a moment of vulnerability, after a particularly busy stretch of per diem work, I found myself complaining about falling behind in documentation to another AT friend. I was tired, hungry, and avoiding documentation, which was the last thing I wanted to do. Trust me, I get it.
PRN Documentation Tips & Tricks:
- Medical Documentation Platform. What platform are you going to use to document? Are there any company required forms you must use? How are you going to keep track of each of the patients you care for?
- Plan ahead! If you are completing online documentation, do you have the ability to have Wifi? A hotspot? A charger for your devices? Shade or some way to be able to see your screens and devices cool? Able to keep documentation private?
- Communication Matters. Did you know that all communication, including verbal and written, to the patient and key people must be documented? Make sure that you are keeping track of who you are speaking to, how you are talking to them, and the information given!
- Stay on Track!: Camps are busy! Make sure that you are not getting behind- that will only make things worse!
- Discharge Notes! When you are working with a patient over time, you must provide a discharge. So how does that work for per diem work? As you are writing the note, the plan part is going to be very important. Did you recommend the patient go to a follow up with the AT?
Check back soon for part II on the Importance of Medical Documentation with Dr. Beth Neil.
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