© 2008 lww chapter 3. injury record keeping. © 2008 lww injury record keeping accurate and...
TRANSCRIPT
© 2008 LWW
Chapter 3. Injury Record Keeping
© 2008 LWW
Injury Record KeepingInjury Record Keeping
Accurate and detailed record keeping is a mandatory part of any
athletic program.
© 2008 LWW
Why Keep Records?Why Keep Records? Communication and quality control Legal considerations Research Injury history Traffic patterns
© 2008 LWW
Communication and Quality ControlCommunication and Quality Control
This is by far the most important reason for keeping records.
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Communication and Quality Control (cont.)Communication and Quality Control (cont.)
With . . . Self
Others involved in the case, and Athlete
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Communication with Self 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.
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Communication with OthersCommunication 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 PhysioTherapeutics. Clip art.)
© 2008 LWW
Communication with Others (cont.)Communication with Others (cont.)
A physician’s efforts are often more efficacious if he or she receives detailed information.
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Communication with Athlete Communication with Athlete
Keeps athlete honest—that is, makes the athlete more compliant with rehabilitation program.
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Legal ConsiderationsLegal 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.
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ResearchResearch
To provide memory so you can compare efficacy of treatments Thus improve methods
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HistoryHistory
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
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Traffic Patterns 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.
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What Records Should Be KeptWhat Records Should Be Kept
Medical information
Incoming student athlete Returning student athlete
Injury evaluation
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What Records Should Be Kept (cont.)What Records Should Be Kept (cont.)
1. Evaluation of Injuries a. Athletic injury report form
2. Treatment of Injuriesa. Daily treatment logb. Individual treatment sheetc. Daily weight-recording form
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What Records Should Be Kept (cont.)What Records Should Be Kept (cont.)
3. Referrals to and from othersa. Medical referralb. Rehabilitation referral
4. Medical Informationa. Incoming student athleteb. Returning student athlete
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What Records Should Be Kept (cont.)What Records Should Be Kept (cont.)
5. Equipment Upkeepa. Ultrasound calibrationb. E-stim maintenancec. GFI checkd. Weight equipment maintenance
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Initialing FormsInitialing Forms
Every entry should be initialed by the person making the entry.
This lets people know who to go to for additional information.
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SOAP NotesSOAP Notes SOAP is an
acronym; each letter represents a section of the patient note.
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SOAP Notes (cont.)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.”
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SOAP Notes (cont.)SOAP Notes (cont.)
O: Objective► Reproducible information the athletic trainer gathers through tests or other evaluative measures
Examples: laxity stress tests, girth, volumetrictests, ROM
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SOAP Notes (cont.)SOAP Notes (cont.)
A: Assessment► Clinician’s professional judgment or impression of the injury
Example: second-degree inversion ankle sprain
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SOAP Notes (cont.)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