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. 2019 Jul;54(7):822-830.
doi: 10.4085/1062-6050-230-18. Epub 2019 Aug 6.

Athletic Trainers' Practice Patterns Regarding Medical Documentation

Lindsey E Eberman  1 , Elizabeth R Neil  1 , Sara L Nottingham  2 , Tricia M Kasamatsu  3 , Cailee E Welch Bacon  4
Affiliations

Athletic Trainers' Practice Patterns Regarding Medical Documentation

Lindsey E Eberman et al. J Athl Train. 2019 Jul.

Abstract

Context: Medical documentation is a required component of patient care in all health care professions.

Objective: To evaluate athletic trainers' perceived behaviors toward, barriers to, and confidence in their medical documentation.

Design: Cross-sectional study.

Setting: Web-based survey.

Patients or other participants: We purchased a list of randomly selected e-mails from the National Athletic Trainers' Association. Of the 9578 participants, 1150 accessed our questionnaire (12.0% access rate), 1053 completed at least 1 portion, and 904 completed the questionnaire in its entirety (85.8% completion rate). Of the participants, 60.1% (n = 569/947) were female, 66.6% (n = 632/949) held a master's degree, 39.3% (n = 414/1053) worked in a collegiate or university setting, and 36.1% (n = 381/1053) worked in a secondary school setting.

Main outcome measure(s): We used a 31-item questionnaire with demographics (12 items), medical documentation behaviors (16 items), barriers (2 items), and perceptions (1 multipart item) sections. The questionnaire explored athletic trainers' behaviors as well as confidence in, comfort with, and concerns about their documentation practices (Cronbach α = 0.887). We used descriptive statistics to identify characteristics of central tendency (mean, standard deviation, mode, frequency).

Results: Participants always (45.7%, n = 478/1046) or very frequently (39.0%, n = 408/1046) used a double documentation system consisting of electronic and paper records (50.4%, n = 523/1038). They most often documented to provide legal protection (86.8%, n = 914/1053), because it is a legal obligation (79.1%, n = 833/1053), or to track patient progress (83.9%, n = 883/1053). The most frequently cited barriers to medical documentation were time (76.5%, n = 806/1053), managing too many patients (51.9%, n = 547/1053), technological concerns (17.2%, n = 181/1053), and software limitations (17.2%, n = 181/1053). Respondents believed they were competent, comfortable, and confident in their documentation practices.

Conclusions: We were able to evaluate the generalizability of previous research while adding to the understanding of the behaviors toward, barriers to, and perceptions about medical documentation. We confirmed that time and patient load affected the ability to perform high-quality medical documentation.

Keywords: documentation barriers; medical documentation behaviors; medical record keeping.

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Figures

Figure 1
Figure 1
Tools used for medical documentation. Abbreviation: EMR, electronic medical record.
Figure 2
Figure 2
Participants' reasons for documenting patient injuries/illnesses.
Figure 3
Figure 3
Documented patient care activities.
Figure 4
Figure 4
Examples of documentation practices for injuries, illnesses, and interventions. Abbreviation: ACL, anterior cruciate ligament.
Figure 5
Figure 5
Items documented in an initial evaluation.
Figure 6
Figure 6
Word cloud illustrating perceived barriers preventing athletic trainers from effectively documenting patient care.
See this image and copyright information in PMC

References

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    1. Welch Bacon CE, Eppelheimer BL, Kasamatsu TM, Lam KC, Nottingham SL. Athletic trainers' perceptions of and barriers to patient care documentation: a report from the Athletic Training Practice-Based Research Network. J Athl Train. 2017;52(7):667–675. - PMC - PubMed

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