Medical Records - PowerPoint PPT Presentation

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Medical Records

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Personal Injury Actions ... Athletic Training Innovations Injury Tracking Software ... Coach's reports ... – PowerPoint PPT presentation

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Title: Medical Records


1
Medical Records
2
Medical Records
  • Data that is considered to be part of the medical
    record
  • Personal
  • Financial
  • Medical

3
Statute of Limitations
  • Length of time in years that a person can file a
    claim
  • Idaho 2 years

4
  • Idaho's Statute of Limitations
  • Preliminary Note Statutes of limitations
    restrict the time period that a person can file a
    lawsuit. These statutes not only vary by state,
    but they also vary by cause of action. The
    following guide provides limitations periods for
    each state, but only for particular causes of
    action specifically, those related to personal
    injury, medical malpractice, and products
    liability claims. The sections discussing special
    rules for minors only apply to the causes of
    action listed for that particular state.
  • Personal Injury Actions
  • These actions must be brought within two years of
    the date the injury occurred.
  • Medical Malpractice Actions
  • Actions against health-care providers must be
    filed within two years of the date that the act
    giving rise to the injury occurred.
  • Products Liability Actions
  • Products liability actions must be brought within
    two years after the plaintiff suffers the injury.
  • Special Rules for Minors
  • The statute of limitations begins to run on the
    minors 18th birthday.

5
Why do we Keep Records?
  • Communication
  • Legal reasons
  • Documentation for reimbursement purposes
  • Research
  • Length to keep records
  • http//www.mcandl.com/idaho.htmlI

6
SOAP Notes
  • Subjective
  • What the patient tells you
  • Objective
  • What you do to the patient (see, palpate, stress
    tests)
  • Assessment
  • What is it?
  • Plan
  • What do you do with the injury?

7
Medical Records Software
  • Electronic Medical Records (EMR)
  • Amazing Charts
  • Medicware EMR
  • Athletic Training Innovations Injury Tracking
    Software
  • Cramer Athletic Injury Management Software
  • CSMI Sportsware Injury Tracking Software

8
Confidentiality
  • Important to have confidentiality agreements
  • Keep records in locked area
  • When working on records, dont leave them out in
    the open for all to see

9
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/2005-06/2005-06_sports_medicine_hand
    book.pdf
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