Medical Records Sports Medicine 9/18/2015 1
Medical
Records
Sports Medicine
9/18/2015 1
Bellwork
Imagine the following scenario: You make
an appointment with your doctor for
your yearly physical and show up at the
right time and date, only to find that the
office has no record of your appointment.
They also have no record of your past
medical history on file, so you have to fill
out the new patient forms. Then you have
to reschedule an appointment since they
have no record of today’s appointment.9/18/2015 Property of CTE Joint Venture 2
Bellwork (cont.)
Please think about the following and be
prepared to share your responses with
the rest of the class.
1. Describe how you would feel if you
found yourself in the situation from the
previous slide.
2. Why is it important to keep accurate
medical records?
9/18/2015 Property of CTE Joint Venture 3
Objectives
1. Identify reasons for keeping medical
records
2. Distinguish between different types of
medical records
3. Create a medical record using
information provided
9/18/2015 Property of CTE Joint Venture 4
Graphic Organizer
PROPERTY OF PIMA COUNTY JTED, 2010 5
Write down information from the
text or presentation into your
graphic organizer
Why keep medical records?
1. Required part of an AT’s professional
practice
2. Communication purposes
3. Legal responsibility
4. Research
5. ROI
6. Reimbursement
9/18/2015 Property of CTE Joint Venture 6
The Facts About Medical Records
Create a detailed, chronological ‘story’ of
a patient’s interaction with health care
providers.
Explain why decisions were made, what
care was provided, and what outcome
was outcome
Help plan and evaluate treatments and
monitor progress
9/18/2015 Property of CTE Joint Venture 7
Identification
Highlight the
different types of
medical records
PROPERTY OF PIMA COUNTY JTED, 2010
Terminology
pre-participation physical
examination (PPE)
◦ a checkup to evaluate a person’s health and
determine if they are able to participate in
sports
9/18/2015 Property of CTE Joint Venture 9
Types of medical records
1. Medical information forms
Personal medical history
Family medical history
Orthopedic history
Pre-participation physical examination (PPE)
2. Injury evaluation form
3. Treatment form
4. Referral form
9/18/2015 Property of CTE Joint Venture 10
Injury Scenario – Part 1
You are an ATSA watching a freshman
boys’ basketball game. You see one of the
players come down and land on another
player’s foot. His ankle is forced into
inversion; he says that he heard a pop.
This is the 2nd time he has injured his R
ankle; the first time was last year while
playing basketball. The athlete is unable to
bear weight.
9/18/2015 Property of CTE Joint Venture 11
Injury Scenario – Part 2
Under the AT’s direction, you observe
that the athlete’s ankle is swollen around
the lateral malleolus. There is no
discoloration or obvious ankle deformity.
During palpation, you note that the
athlete is point tender over the anterior
talofibular and calcaneofibular ligaments.
His capillary refill is good and he has a
strong dorsal pedis pulse.
9/18/2015 Property of CTE Joint Venture 12
Injury Scenario – Part 3
Athlete’s motion in dorsiflexion and
inversion are limited by pain; you do not
test his strength at this time because of
pain.
Your evaluation is as follows:
(-) compression and bump tests
(+) anterior drawer test
(-) talar tilt in inversion
(+) talar tilt in eversion
9/18/2015 Property of CTE Joint Venture 13
Injury Scenario – Part 4
Since the athlete is unable to bear weight,
you do not do any functional testing at
this time.
You follow the RICE protocol for soft
tissue injuries. After icing/elevating for 20
minutes, you apply an Ace wrap for
compression and instruct athlete on the
use of crutches – NWB. You also instruct
the athlete to report to the training room
tomorrow after school.9/18/2015 Property of CTE Joint Venture 14
PROPERTY OF PIMA COUNTY JTED, 2010 15
Snapshot
Write a
“snapshot” of
today’s learning
about medical
records in 25
words or less.