Cheat Sheet: Medical Documentation for People in a Hurry

“If you didn’t document it, it didn’t happen.” I remember hearing this early in my athletic training education; It may have even been on my first day in the program. Medical documentation is critical to protect healthcare professionals and organizations they work for from liability. It also protects the patients, obviously. What documentation does is provide a comprehensive record for each patient. Most of my athletic training career was spent in the traditional setting working at different colleges. For those of you who aren’t familiar with this employment setting, they are not similar to a doctor’s office of physical therapy office that you may be more familiar with. While there can be formal appointments, most of the health care interactions a college, and even high school, athletic trainer have are unplanned, unannounced, and often can be unpredictable.

This article is for anyone who is looking for tips on how to effectively document important information when you don’t have a lot of time. Even if you don’t work in healthcare, I hope you find this helpful.

Case study

It’s the end of the day. You just finished covering practice, you taped 12 ankles, did 14 treatments, evaluated 2 minor injuries, had an acute injury you evaluated during practice, had your team physician evaluate one of your players, coached 4 rehab sessions, drank 1 bottle of water, and drank your body weight in coffee. You want to go home but haven’t documented all of the things that happened throughout the day and you want to go home.

Most athletic trainers are very familiar with this type of day. It’s honestly a very typical day for a college and/or high school athletic trainers’ day. It’s really easy to want to throw in the towel and give in to the fallacy of “I’ll do it when I get home” or “I’ll do it tomorrow.”

So, what do you do here?

There’s a few ways to ensure that when you find yourself in this situation, you aren’t on a the computer for an hour after work.

Templates

If your EMR system has templates, use them. Most of them have a SOAP note format to use. Some even have a formatting option where you can use dropdown templates for objective testing. Look into how your EMR has templates and how to use them (youtube is great here).

If you use rehab charts, simply log everyday on the chart. When you document a patient did rehab that day in your EMR, you don’t have log all that they did: it’s in their rehab chart.

Quick functions

Most EMRs I’ve worked with have a quick functions where you can quickly go to document things like taping, rehabilitation, evaluations, treatment sessions, etc. Typically, these functions allow you to add notes in as well. This is one stop shopping. You can put down all of your treatments and write quick notes on each interaction in one page.

Use appointments

Have your patients make appointments. Some EMRs can do this, you can use a google doc, an appointment booking server, or any other methods that may work for you. You’ll likely get some pushback on this if you haven’t done it before. If you do, ask your patients, coaches, parents, or whomever this question: Do you think you can walk into a doctor’s office or a physical therapy office without an appointment and expect to receive care?...Why do you think my athletic training department is any different?” If you have patients schedule appointments, you can always reference at the end of the day who you saw and who you didn’t see. Even if you don’t have 100% of your interactions on the schedule, you will be surprised how easily you remember who you saw when you can visualize your day.

Find what works for you

Some people like to document as they go. Others like to batch their documentation and do it all at once. Do what works for you, but make sure you get it all done. You may need to adapt to what your day throws at you, but if you can create a system for yourself it can help your time management.

Write notes to yourself

I write notes for myself all the time, it helps me remember. Post-notes, the notes app on the phone, random pieces of paper, they all work when needed. If you write things down in a HIPAA compliant way, you’ll be less likely to forget important information. This is important because you’re going to get interrupted, don’t let that prevent you from doing the job later. It also will allow you to handle things easily when they come up in the moment.

Use Common Sense

If an injury requires a referral, imaging, rehabilitation, or treatments they must be documented. Non-negotiable. A cut or blister should be documented too, but you may not be able to get these all done. I’m not advocating omitting these from your notes, but I do recognize things may get missed, we’re human. Never forget to document injuries, medical conditions, important medical history, etc.

Think worst case scenario

If the answer to the question: “could not documenting this somehow screw me over if I get audited or sued?” The answer to this question is often “yes,” so you should document.

The more that you document, the more value you can show

If you have documentation, you have data. If you have data, you can show value. If you can show value, you can get things you may want such as budget increases, extra staff, raises, and even show cost containment. It’s always a good idea to have more information.

I hope these tips have been helpful, or at least a good refresher for those looking to improve their documentation skills. While tedious, it’s the most important part of our job as a healthcare professional. It must be treated as a priority, even though it can be a bother.

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