© 2008 LWW Chapter 3. Injury Record Keeping

© 2008 LWW Injury Record Keeping Accurate and detailed record keeping is a mandatory part of any athletic program.

© 2008 LWW Why Keep Records ? Communication and quality control Legal considerations Research Injury history Traffic patterns

© 2008 LWW Communication and Quality Control This is by far the most important reason for keeping records.

© 2008 LWW Communication and Quality Control (cont.) With... Self Others involved in the case, and Athlete

© 2008 LWW Communication with Self It is hard to keep all the details of individual cases straight without written records. A periodic review of cases helps you see progress. A review may stimulate ideas for improved treatment.

© 2008 LWW Communication with Others All members of the team should know what the others have done, creating continuity. Without records, the efforts of each will be isolated rather than being part of a coordinated whole. It is confusing to an athlete to get conflicting advice about his or her problem. (Used with permission from Castel D. International Academy of Physio Therapeutics. Clip art.)

© 2008 LWW Communication with Others (cont.) A physician’s efforts are often more efficacious if he or she receives detailed information.

© 2008 LWW Communication with Athlete Keeps athlete honest—that is, makes the athlete more compliant with rehabilitation program.

© 2008 LWW Legal Considerations The value of a document depends on its accuracy and detail. Most lawsuits occur years after the event, usually after the memory of specific details is gone. Written records supply memory.

© 2008 LWW Research To provide memory so you can compare efficacy of treatments Thus improve methods

© 2008 LWW History Specific and detailed information is important to a variety of people: Insurance company College and professional recruiters Military Some employers Need for information often occurs months after the injury occurred

© 2008 LWW Traffic Patterns Establish daily, weekly, monthly, and yearly traffic patterns. Such records can be the clincher in verifying the need for additional facilities and/or staff or in preventing cuts in the program.

© 2008 LWW What Records Should Be Kept Medical information Incoming student athlete Returning student athlete Injury evaluation

© 2008 LWW What Records Should Be Kept (cont.) 1. Evaluation of Injuries a. Athletic injury report form 2. Treatment of Injuries a. Daily treatment log b. Individual treatment sheet c. Daily weight-recording form

© 2008 LWW What Records Should Be Kept (cont.) 3. Referrals to and from others a. Medical referral b. Rehabilitation referral 4. Medical Information a. Incoming student athlete b. Returning student athlete

© 2008 LWW What Records Should Be Kept (cont.) 5. Equipment Upkeep a. Ultrasound calibration b. E-stim maintenance c. GFI check d. Weight equipment maintenance

© 2008 LWW Initialing Forms Every entry should be initialed by the person making the entry. This lets people know who to go to for additional information.

© 2008 LWW SOAP Notes SOAP is an acronym; each letter represents a section of the patient note.

© 2008 LWW SOAP Notes (cont.) S : Subjective ► Information gathered primarily from questioning the athlete about his or her present condition Example: “I twisted my ankle, and it hurts right here.”

© 2008 LWW SOAP Notes (cont.) O : Objective ► Reproducible information the athletic trainer gathers through tests or other evaluative measures Examples: laxity stress tests, girth, volumetric tests, ROM

© 2008 LWW SOAP Notes (cont.) A : Assessment ► Clinician’s professional judgment or impression of the injury Example: second-degree inversion ankle sprain

© 2008 LWW SOAP Notes (cont.) P : Plan ► Course of action that the athletic trainer and the patient will take to treat and rehabilitate the injury; includes both short- and long-term goals