Importance of Documenting
Updated
by
Niki Budd
Importance of Documenting
Documentation is a vital responsibility for Athletic Trainers. Let's discuss why and the ways to improve the process.
Recorded Webinar:
Why Document:
- Professional Responsibility
- Serves to provide a complete, accurate, and timely record of a patient's complete medical history
- Increases communication and ensures a consistent level of care across providers
- Decreases risk of litigation
- Promotes you, the provider!
What to document:
- Patient encounters: are any interaction with a patient when an athletic training service is, provider, or communication occurs regarding their health status.
- Informed consent: at minimum, you should include the following:
- type of care/intervention to be rendered
- the benefits and risks associated with the care/intervention
- the discussion that alternatives were discussed
- that they understand and agree to the proposed care/intervention
Rules and Regulations:
- State Practice Acts: documentation laws differ from state to state; providers should be aware of their induvial state practice acts to ensure proper documentation as well as adhere to be best practices for documentation recommended via NATA
- NATA Best Practice Guide
- BOC Appropriate Documentation
- Federal Laws: Each state is regulated by federal laws that ensure the protection of PHI and academic records. Organizations should develop their own written policy and procedures to ensure HIPAA and FERPA standards.
- Health Insurance Portability and Accountability Act (HIPAA)
- Federal Education Rights and Privacy Act (FERPA)
- Legal Responsibility: It's the responsibility of the AT to keep administration, employers, legal counsel, and supervising physicians current with state practice acts and rules and regulations for the state in which one practices.
How can Healthy Roster Enhance documentation:
- When you create an established standard via documenting, you will increase the standard of care for your patients as well as increase communication
- You are able to better audit your providers for accuracy, timely documenting, and quality of record keeping
