Future Strategies to Enhance Patient Care Documentation Among Athletic Trainers: A Report From the Athletic Training Practice-Based Research Network

Mode of Documentation

Clinicians described using paper forms, electronic medical records (EMRs), or a combination of both techniques to document patient care. Lund preferred documenting on paper and shared:

I just like writing everything down. For me it's a memory thing. In the EMR, it's really easy to go “click, click, click.” And so from a time perspective, it's very easy to have all of that, but I am just a pen-and-paper person. I like writing everything down. It helps me remember everything when I am dealing with the patient.

Baker documented on paper before transferring the information to an EMR, saying:

At the beginning of each day, I have a pen and notepad with me, and I write down each patient's name and condition of what they have and any small medical notes that I'll write below them. . . . At the end of the day, I take my notepad and paper of patient encounters and I'll transfer into my EMR.

Conversely, Lang preferred EMRs, explaining, “[I have used] a number of different forms as far as paper based. And then I try to put them in folders, tried it with binders, that sort of thing. The electronic is just so much more efficient.” Similarly, Stalter remarked, “I really like using the EMR and since I started using that, it has made my life easier, because it's so much easier to type everything out than try to write it out.”

However, Taylor was not sure which mode was preferable:

There are certain things that I like about both. It's really convenient to be able to have all my paper copies in an accordion-style folder, and just pull them out in the middle of the game when you are doing an evaluation. But it is also nice to have things stored on the computer, especially if you know that it is secure and protected. So I guess I'm kind of torn on that one.

Consistency

In general, ATs described a lack of consistency regarding documentation practices. Lang observed differences between clinicians and stated, “There are so many out there that it seems like everybody is using their own system.” Murphy echoed, “I know [documentation strategies] can't possibly be uniform all over but especially for high schools, it's varied from site to site. Some only use paper, and some are inconsistent.” Blynn made a similar comment:

We have accident report forms at the high school and they honestly were like workman's comp forms. So they really didn't even make sense. I feel like there's just no consistency on how things are getting done at the high school level.

However, Baker reflected on the consistency of personal documentation practices:

I think just being able to be consistent with that care and not allowing myself to fall into those bad habits to begin with. . . . And by [consistent] I mean documenting the same, whether it's the beginning of the year or the end of the year, the middle of the season or whatever.

Standardization Process

Partially due to a lack of consistency in documentation systems and processes, ATs commented on how they standardized their processes for completing their patient care documentation. Setting aside time to document patient care was important. Taylor noted, “It typically works better, I think, if you can schedule your time out a little bit better. . . . So it kind of cuts down on stacking up the files that you might need to get documented.” Similarly, to complete patient care documentation, Peters recommended, “Just set aside some kind of block, an hour a day, to where no one comes in, no one comes in for treatment.”

To develop a standardized process for documenting, participants described creating a routine. Murphy shared the importance of “[creating] your own system that works for yourself while making sure that you do include everything that you need to.” An individualized routine was also necessary for Carter:

[When] I started, at first I was like “you've got to be kidding. This is absurd.” Each year I had a new strategy on how to make it a little bit better. So now I am just finally comfortable, but it was quite a learning curve.

Similarly, Baker focused on standardizing a personal routine:

I would say for the most part that, you know, I'm pretty standard. I don't like to vary too much between my initial and my follow-up because I think it just makes it a little easier to track their progress. If my initial evaluation is much different from a follow-up, I feel like things can get a little confusing. So I try to keep them pretty much format wise, pretty much the same.

The behaviors of student-athletes were also integrated into the standardization process. Lang described having difficulty with student-athletes completing patient surveys:

Once I established a policy, it became much easier with [student-athletes]. They seem to understand it now. And it has become more of a routine with myself. I don't forget about it or anything like that, and that was part of my problem. I was forgetting and then I'd have to go back and call them back in and try to do that. Now I have more of a routine set … I am able to stay on top of that.

System Standardization

In addition to following their own protocols for documenting to improve consistency and quality, ATs discussed the potential benefits of having a standardized system for documenting patient care. Blynn remarked:

I think, and especially with online documentation, some programs or some software you can just send a message, or you can just click on that patient note and it's in there. With bigger hospitals, you just have 1 system between several departments, and it's easy to share information. It gives them better care. You're not doing things twice.

Similarly, Baker commented:

So I feel like that if there was a good documentation system that could have some sort of interprofessional or if there was a way that [health care professionals] could communicate easily with me through my documentation, that the consistency of care that these patients need could be achieved. So it's definitely along the lines of being able to provide consistent, thorough, and safe care for those patients.

To aid in communication and follow-up, Peters created a site-specific system and shared:

That was something that we made to make it easier for us to communicate. I'm the type of person that . . . it's much easier for me to grasp it if I'm looking at a list. . . . This way we knew we needed to follow up, that we needed to send them to a doctor, if we could clear them, if it's been 2 weeks since they've even been in, let's follow up. So that was a way for us to go through and know we were up to date. That was our system to it.

On a broader level, Carter commented on the lack of system standardization across the profession:

There are just so many systems. And people go “well I do it like this, I do it like this.” Maybe there's no uniform system. Maybe there is. . . . If you took 10 athletic trainers and ask[ed] them all their systems, if they didn't use the EMR, you're probably going to get 10 different answers.

Ways of Learning

Most ATs described their first exposure to patient care documentation during their professional education programs. Taylor stated, “I know in undergraduate [courses], we talked about documentation. It was kind of just the basics.” Blynn echoed, “I think we had a little bit in undergraduate incorporated into one of our athletic training courses. And then as a clinical student, I didn't really have to do a lot of documentation.” Conversely, Baker noted, “A majority of it came through graduate coursework. . . . Definitely that's where a lot of the technique and habits I gained were through the graduate school.”

Clinicians also described learning about patient care documentation during clinical education. Carter explained, “Most of [the documentation] was practiced with the athletes that we took care of in college. So my clinical setting was where we practiced it and got feedback, and our work was checked.” Quality documentation was particularly relevant for Heron:

The university where I did my undergraduate, they did third-party billing and reimbursement for their college athletics. And the head athletic trainer also taught our administration class. So documentation was a very, very big part of our classroom learning, and also we learned from very early on, like once we were second-year students and were working with sports teams, we were helping with documentation. We had to make sure that everything was very comprehensive.

In contrast, Murphy had little practice documenting patient care:

As a student, I don't feel like you get to practice at the site that you are at, because you are not the athletic trainer, you are just there observing and helping. At least that was my experience. I don't feel like I was able to document or get practice documenting like I would have wanted to.

In addition to professional education, ATs also enhanced their knowledge of patient care documentation via continuing education opportunities. Building upon professional education on patient care documentation, in rare instances ATs commented on brief discussions regarding the topic at continuing education workshops. Lang remarked:

I know that the seminars that I go to, there always seems to be something about documentation and making sure that you do all the documentation properly. [I learned] while I was in my field experience how other athletic trainers were doing their documentation.

However, Carter elaborated on the lack of clarity or suggestions provided at continuing education events regarding quality documentation practices:

When you go to a conference, they will say, “You should document.” And it's just always very general. . . . I would sit there and go, “Well, yeah. That's why I am here.” They would just tell you how important it was, and how it helps you legally, and how it could help you to count how many people you see and it could help support your job. But it never told you really how to do that. It just told you all the things that it could do and it should do, but it didn't tell you how.

In some cases, ATs described a learning process over time regarding patient care documentation driven by their own desire to refine their practices. Baker shared, “It's been through kind of trial and error because I worked with several different documentation styles.” Carter described a similar experience of personal reflection when changing documentation practices:

I came in and said, “You know in my past, here were my weaknesses [in documentation], and I need to start off well in this job with what I want to do.” So there were things that I came in with goals right away.

Strategies for Future Education

In general, ATs discussed the importance of introducing students to patient care documentation at the start of their professional programs. Baker commented, “If you can ingrain that early and often, it just becomes really something that is second nature to somebody.” Peters reiterated the emphasis on early integration:

Those documentation techniques and usefulness will improve if we have the students do that from an early start. If that is all they're used to, then they will just continue in their professional careers.

Similarly, Blynn explained:

And then you could teach your students those programs and they're getting it earlier and refining their skills, rather than learning it at clinical. And every clinical instructor has a different way of doing it or every setting has something different. So I think consistency and starting it earlier.

Clinicians also suggested providing specific strategies and opportunities for students to practice patient care documentation. Stalter expressed the need for a “stronger emphasis on [patient care documentation] in the professional and postprofessional education programs . . . not only in the classroom, but the clinical education side of things.” Taylor noted:

I think maybe if the coursework went a little deeper into some more documentation techniques or strategies, or even just introducing 2 different types of software for documentation, but that could be really useful.

Similarly, Stalter said:

I think an earlier introduction into EMRs would be nice. It made documentation seem like it was a lot less of a task and more of a thing that I could accomplish with little struggle, as opposed to before.

Heron observed:

I think helping educate people that maybe are not aware of what should be documented and then giving them options for how to document in a relatively quick fashion in multiple ways. So showing them how to maybe make forms if a computer is not an option for them at their site. Because it still gives you the documentation that you minimally should have but isn't going to be a huge burden of time. So just giving them some ideas and showing them ways to implement it, without adding a lot of extra stress or work to them.

In addition to earlier exposure and specific strategies, ATs proposed specific formats for education or ways to contextualize the importance of patient care documentation. Heron suggested:

I think a Webinar would be good. I think something that is interactive, where people can go through together. . . . Like show a standard lower body evaluation form that they could just use a pen and paper for, or that sort of thing. And then show them an example of an electronic medical record that they could use, and talk about minimum requirements. . . . Because I think a lot of athletic trainers don't think they really need much at all or there may be some that [are] doing overkill, and it's a big burden on them because they are spending a lot of time documenting, and perhaps maybe they are doing a little more than they need. And that could help reduce their stress.

Peters commented:

Maybe [the] NATA [National Athletic Trainers' Association] points out some of the worst-case scenarios: maybe case studies where documentation was done poorly and hurt the AT. That might get people to say, “Yeah that might be important.”

Lund also advised using case scenarios to contextualize the legal aspects of patient care documentation:

You can tell people all day that of course it's going to help them improve their patient care, but really what it comes down to is . . . in this day and age, people are going to sue you for anything, so you want to make sure you have all of your bases covered.

Professional Athletic Training Education

Participants in our study also stated that they initially developed their documentation habits as athletic training students. Most participants recalled completing only 1 formal class session within a documentation course, and by and large, learned how to document during their clinical education experiences. However, this approach was perceived as problematic and likely contributed to inconsistencies.⁷ In general, participants felt that the best way to improve patient care documentation habits in the athletic training profession was to focus on teaching athletic training students the fundamentals of documentation early and then continually revisit the topic throughout their clinical education. This approach will require good habits to be modeled by preceptors routinely at the point of care. Dodge and Mazerolle²⁵ reported that by providing students with real-life learning experiences, preceptors can influence students' development and commitment toward athletic training. Thus, successful preceptor modeling and mentorship of patient care documentation that includes realistic learning opportunities for integrating documentation into routine patient care would highlight and reiterate the importance of patient care documentation for students, ingrain good documentation habits, and allow any poor habits to be addressed before becoming an AT.

Currently, 3 competencies related to patient care documentation are included in the fifth edition of the National Athletic Trainers' Association's Athletic Training Education Competencies.²⁶ However, our participants stated that their education on patient care documentation primarily addressed understanding why such documentation was important and provided little guidance regarding what and how to document. Based on the perceptions of our participants, the current athletic training educational competencies related to patient care documentation may need to be further detailed. Concentrating more on what should be included in patient care documentation and how to complete documentation that is considered high quality may minimize ATs' current uncertainties about documentation.

As the Athletic Training Education Competencies²⁶ transitions to the “Curricular Content Standards” under the Commission on Accreditation of Athletic Training Education, 1 standard is proposed to specifically focus on patient care documentation. This standard states that graduates of a Commission on Accreditation of Athletic Training Education–accredited professional athletic training program must “use contemporary documentation techniques to effectively communicate with patients, medical professionals, insurers, and other relevant stakeholders. These include using a comprehensive electronic medical records management system (including diagnostic and procedural codes) for appropriate chart documentation, risk management, outcomes and billing.”²⁷ The intent of this standard is not only to educate students about the importance of patient care documentation but also to stress the importance of being competent in the use of EMRs and diagnostic and procedural coding as well as in outcomes assessment and billing as parts of patient care documentation. Thus, although students must learn an abundance of knowledge and skills during their professional athletic training programs, the significance and value of patient care documentation must not be forgotten.

As professional athletic training programs continue to integrate the “Curricular Content Standards,” educators and clinical preceptors should not only emphasize the logistics of patient care documentation, but they should also encourage students to consider the value of high-quality patient care documentation for continuous quality improvement. Clinical and classroom educators should teach consistent and thorough mechanisms for patient care documentation. In addition, the use of a standardized evaluation form to assess the thoroughness of students' patient care documentation, such as the History and Physical Assessment form,^28,29 should be considered to help instill good patient care documentation habits among students. A formal evaluation form for patient care documentation may also offer a mechanism for preceptors to provide consistent, standardized feedback to students, which has been shown to improve students' performance of patient care documentation.²⁹ Finally, students should learn how their patient care documentation can be used to demonstrate value, improve patient outcomes, and contribute to practice-based evidence.

Continuing Education

In addition to enhancing the focus on patient care documentation in professional athletic training programs, it is also necessary to address the current knowledge-to-practice gap regarding the uncertainties associated with patient care documentation among practicing ATs. The participants in our study felt that specific continuing education efforts focused on patient care documentation would be helpful for practicing clinicians. Furthermore, they emphasized that although it is beneficial to continue to discuss the importance of patient care documentation to be able to characterize the value of the athletic training services we provide, we must focus on the specifics of what and how to efficiently and effectively document patient care in the various and unique athletic training clinical practice settings. Whereas the NATA Documentation and Coding Guidelines for Athletic Trainers²¹ provides a starting point for which variables should be documented from each patient encounter, some uncertainty remains regarding what type of patient encounters and patient injuries should be documented.

Athletic training practice has expanded from the traditional athletic environment to emerging practice locations such as rehabilitation clinic, industrial, performing arts, military, and other diverse settings. As different athletic training skill sets are applied in different settings, documentation mechanisms may also vary among settings and patient populations. In addition, an increasing number of ATs are also able to bill for services,³⁰ which often require additional documentation, such as Current Procedural Terminology codes. These components of documentation were not included in the professional education of many clinicians who are currently practicing. Thus, continuing education opportunities specific to these emerging practice settings and increased documentation requirements are needed to support practicing clinicians.

Along with identifying what should be included in high-quality patient care documentation, continuing education efforts should provide clinically meaningful examples of good documentation (ie, real-life examples of quality improvement) compared with examples of poor documentation (ie, real-life scenarios of patient care documentation that would not hold up in a court of law). These real-world examples may motivate individuals to reflect on their current patient care documentation habits and consider how they might incorporate strategies to enhance their current routines. In fact, continuing education opportunities that were interactive and focused on outcomes that were important to clinicians were more effective.³¹ In our study, many of the ATs who were successful in documenting patient care made a direct and conscious decision to do so and reprioritized patient care documentation as part of their daily clinical practice.