Medical Documentation

1
Medical Documentation Pre-Physical Examination
(PPE)
2
Why do we Keep Records?

• Communication
• Legal reasons
• Documentation for reimbursement purposes
• Research
• Records Retention
• Depends on organization
• Statute of Limitations state law that gives
  length of time that a person has to file a claim
• Idaho 2 years

3
Essential Information Needed for Medical
Documentation

• Signatures on any legal forms that may be
  required for participation.
• If the athlete is not of legal age, the parent or
  guardians signature must be obtained.
• Address telephone information
• Emergency Contact information
• Health Insurance information
• Health Status information

4
What Records Should be Kept?

• History form
• Physical examination form
• Parents information Emergency contact
  information
• Insurance information
• Informed consent
• Release of medical records
• Release waiver of liability
• Evaluations, progress notes

• Assumption of risk
• Helmet liability release
• Heat acclimatization
• Treatments rehab forms
• Coachs reports
• http//www.ncaa.org/library/sports_sciences/sports
  _med_handbook/2006-07/2006-07_sports_medicine_hand
  book.pdf

5
Medical Records Software

• Electronic Medical Records (EMR)
• Simtrak - http//www.simtrak.com
• Amazing Charts http//www.amazingcharts.com
• Medicware EMR http//www.medicware.com
• Athletic Training Innovations Injury Tracking
  Software - http//www.edu-technology.com/healthsci
  ence.html
• Cramer Athletic Injury Management Software
  http//www.cramersportsmed.com/products_catalog.js
  p?catID113prodID232pathAT

6
Medical Records Software

• CSMI Sportsware Injury Tracking Software -
  http//www.csmisolutions.com/sw/main.shtml
• Injury Tracker - http//www.injurytracker.com/
• Athletic Training Action - http//www.onlinesport
  s.com/pages/I,CR-131725.html

7
Confidentiality

• Important to have confidentiality agreements
• HIPAA Health Insurance Portability
  Accountability Act
• FERPA Family Educational Rights Privacy Act
• Keep records in locked area
• When working on records, dont leave them out in
  the open for all to see

8
Components of PPE
9
Components of PPE
10
Components of PPE
11
Blood Analysis

• Hematocrit (Hct) - of red blood cells (RBC) in
  blood Avg. males 40-54 Avg. females
  38-47
• Athletes may have higher-than-normal hematocrit
  due to constant physical activity rather than a
  pathological condition.
• Hemoglobin (Hb) the iron containing pigment of
  the red blood cells it is responsible for the
  transportation of oxygen from the lungs
• Sickle Cell an unusually shaped RBC can become
  trapped unable to exit capillary wall because
  of shape. Athletes with sickle cell anemia or
  trait are _at_ risk of complications during exertion

12
Urine Analysis

• Specific Gravity indicates level of hydration
  water is 1.000 the greater the concentration,
  the higher the specific gravity.
• Sugar Diabetes if sugar in urine is elevated
  to between 80 and 120 mg/100 ml
• Ketone bodies high appearance may be caused by
  diabetes mellitus, starvation, or too little
  carbohydrate in the diet.
• pH range between 4.6 and 8.0 variations are
  usually related to diet
• high-protein diet increases acidity (pH less
  than 7)
• diet largely of vegetables increases alkalinity
  (pH greater than 7)