Record Keeping
-All records must be accurate and up-to-date. These include the following: medical records, injury reports, insurance information, injury evaluations, progress notes, equipment inventories, and annual reports.
Maintaining Confidentiality in Record Keeping
- HIPAA (Health Insurance Portability and Accountability Act)
-regulates dissemination of health information
-protects patient's privacy and limits the people who could gain access to medical records
FERPA (Family Educational Rights and Privacy Act
-law protecting privacy of student education records
Administiring Pre-participation Exam
-Initial pre-participation exam prior to start of practice is crucial
-It establishes a baseline
-It establishes a baseline
SOAP note format
-S: Subjective (history of injury/illness) Ex: What they tell you
-O: Objective (info gathered during evaluation) Ex: What you see, feel etc.
-A: Assessment (opinion of injury based on info gathered during evaluation) Ex: What you think it is
-P: Plan (short and long term goals of rehab) Ex: How you plan to fix it
-O: Objective (info gathered during evaluation) Ex: What you see, feel etc.
-A: Assessment (opinion of injury based on info gathered during evaluation) Ex: What you think it is
-P: Plan (short and long term goals of rehab) Ex: How you plan to fix it