How Athletic Trainers Can Improve Documentation

Documentation is vital to maintaining records and providing quality care. But many ATs are spending 25% or more of their time documenting. This not only affects direct patient care, it affects you... and your time. What can you do to improve documentation? 

Just as in home repair or remodeling, having the right tools makes work easier. Without the proper tools, you could end up spending even more time and money to get the job done.

Tool #1

Whether you are employed by a school or hospital, it is vital that you take advantage of technology available today in the form of Electronic Medical Records (EMR) solutions.

If you're not already using an EMR, there are a lot of advantages. An EMR helps you: 

• Provide accurate, up-to-date and complete details about your athletes at the point of care
• Enable easy and fast access to patient records for more coordinated and efficient care
• Share info with patients and other providers electronically
• Help the team effectively diagnose patients, reduce errors and provide safer care
• Improve interactions and communication with everyone involved
• Promote accuracy and legibility in documentation
• Streamline coding and billing
• And boost privacy and security of PHI

Tool #2

If you use your phone or another recording device to dictate, you can take advantage of transcription services. You can pay them to deliver error-free transcripts of SOAP notes, consultations, evaluations, referral letters and medical or legal reports. 

They have systems in place to deliver consistent, reliable, and timely documentation. You just have to send them your dictation, which they download, and then the audio is transcribed and converted to electronic files in the required format, and then they check for accuracy, and finally the files are returned via secure FTP into your EMR. 

Tool #3

Investing in a quality medical records scanner can save time, maintain privacy, and reduce paper. 

You can improve efficiency, reduce data entry errors, more easily search for and find documents, and cut costs (reduced paper, storage space, file boxes, etc.) 

Tool #4

Hire an encryption service to make sure you can communicate securely through text messages. HIPAA compliance and PHI must be met with any solution you utilize. 

Additional Tools

• Find a reporting software solution that allows you to compile all your data and then to make and send reports on injuries, treatment logs, rehab, progress, referrals, and whatever else is needed.
• Having a quality laptop is essential for Athletic Trainers. One that can contain your EMR, connect with your scanner, and communicate with your transcription service. And one that can handle being transported to away games and be taken home with you at night for further documentation. 
• Keep a list of all the names, email addresses, and phone numbers for ADs, coaches and maybe even parents and athletes to improve communication. Update it regularly each season to make sure you can let everyone know statuses and updates. 

Conclusion

There are a number of tools available to help Athletic Trainers improve documentation and save time. Take advantage of new technology, implement as many of these solutions as possible, and improve your processes. 

Another alternative to consider is that Healthy Roster provides these tools all in one platform and can eliminate the need to carry around a pen and paper, a dictation device, and a heavy laptop. And even use your phone to securely scan and store documents - all in a single EMR built exclusively for Athletic Trainers.

Document and communicate with us to save time and avoid all the additional purchases and services. Want to learn more? Talk to us and we'll show you how it works!