Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network

Abstract

Context: Documenting patient care is an important responsibility of athletic trainers (ATs). However, little is known about ATs' reasons for documenting patient care and the mechanics of completing documentation tasks. Objective: To understand ATs' perceptions about reasons for and the mechanics of patient care documentation. Design: Qualitative study. Setting: Individual telephone interviews with Athletic Training Practice-Based Research Network members. Patients or Other Participants: Ten ATs employed in the secondary school setting (age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) were recruited using a criterion-based sampling technique. Participants were Athletic Training Practice-Based Research Network members who used the Clinical Outcomes Research Education for Athletic Trainers electronic medical record system and practiced in 6 states. Data Collection and Analysis: We used the consensual qualitative research tradition. One investigator conducted individual telephone interviews with each participant. Data collection was considered complete after the research team determined that data saturation was reached. Interviews were transcribed verbatim and independently analyzed by 4 research team members following the process of open, axial, and selective coding. After independently categorizing interview responses into categories and themes, the members of the research team developed a consensus codebook, reanalyzed all interviews, and came to a final agreement on the findings. Trustworthiness was established through multiple-analyst triangulation and member checking. Results: Participants identified 3 reasons for documenting patient care: communication, monitoring patient care, and legal implications. Four subcategories emerged from the mechanics-of-documentation theme: location, time of day, length of time, and criteria for documenting. The ATs described different criteria for documenting patient care, ranging from documenting every injury in the same manner to documenting time-loss and follow-up injuries differently. Conclusions: Whereas ATs recognized individual mechanisms that enabled them to document patient care, they may need more guidance on the appropriate criteria for documenting various patient care encounters and strategies to help them document more effectively.

Athletic Trainers' Perceptions of and Barriers to Patient Care Documentation: A Report From the Athletic Training Practice-Based Research Network

“…The research team, which comprised 6 ATs who had various levels of experience with the CQR tradition, was described in an earlier study. 16…”

“…Training procedures for the CORE-AT EMR have been described. 16 Data saturation was confirmed after the inclusion of 10 ATs who met the predetermined criteria. Participants were 4 men and 6 women (age ¼ 32.6 6 11.4 years, athletic training experience ¼ 7.1 6 7.8 years).…”

“…The demographics of this sample were described in an earlier study. 16 All participants provided written informed consent via e-mail before scheduling an individual interview, and the study was approved by the institutional review boards of A.T. Still University and Chapman University.…”

Athletic Training Services During Daily Patient Encounters: A Report From the Athletic Training Practice-Based Research Network

“…Together, these results indicate that ATs may spend a considerable amount of time managing nontimeloss injuries due to the greater volume and amount of care associated with nontime-loss injuries compared with timeloss injuries. Further, in ongoing investigations 23,24 aimed at understanding ATs' documentation habits, the researchers reported that ATs were more likely to formally document time-loss injuries, possibly due to their perceived significance and severity, than nontime-loss injuries within the patient-documentation portion of an EMR. We noted that only 37.7% of all current injury encounters were associated with an injury that was formally documented within the patient-documentation portion of the EMR.…”

Research at the Point of Care: Using Electronic Medical Record Systems to Generate Clinically Meaningful Evidence

“…23 Despite these potential benefits, it is evident that ATs do not comprehensively document care and use EMRs to their full capacity. [24][25][26] Several groups have analyzed patient care documentation in athletic training, particularly for injury surveillance. For example, researchers have used the National Collegiate Athletic Association Injury Surveillance Program and High School Reporting Information Online system for a decade to describe the injury and exposure data of athletes participating in 13 collegiate and high school sports.…”