Medical Records

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Medical Records
2
Medical Records

• Data that is considered to be part of the medical
  record
• Personal
• Financial
• Medical

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Statute of Limitations

• Length of time in years that a person can file a
  claim
• Idaho 2 years

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• Idaho's Statute of Limitations
• Preliminary Note Statutes of limitations
  restrict the time period that a person can file a
  lawsuit. These statutes not only vary by state,
  but they also vary by cause of action. The
  following guide provides limitations periods for
  each state, but only for particular causes of
  action specifically, those related to personal
  injury, medical malpractice, and products
  liability claims. The sections discussing special
  rules for minors only apply to the causes of
  action listed for that particular state.
• Personal Injury Actions
• These actions must be brought within two years of
  the date the injury occurred.
• Medical Malpractice Actions
• Actions against health-care providers must be
  filed within two years of the date that the act
  giving rise to the injury occurred.
• Products Liability Actions
• Products liability actions must be brought within
  two years after the plaintiff suffers the injury.
• Special Rules for Minors
• The statute of limitations begins to run on the
  minors 18th birthday.

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Why do we Keep Records?

• Communication
• Legal reasons
• Documentation for reimbursement purposes
• Research
• Length to keep records
• http//www.mcandl.com/idaho.htmlI

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SOAP Notes

• Subjective
• What the patient tells you
• Objective
• What you do to the patient (see, palpate, stress
  tests)
• Assessment
• What is it?
• Plan
• What do you do with the injury?

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Medical Records Software

• Electronic Medical Records (EMR)
• Amazing Charts
• Medicware EMR
• Athletic Training Innovations Injury Tracking
  Software
• Cramer Athletic Injury Management Software
• CSMI Sportsware Injury Tracking Software

8
Confidentiality

• Important to have confidentiality agreements
• Keep records in locked area
• When working on records, dont leave them out in
  the open for all to see

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What Records Should be Kept?

• History form
• Physical examination form
• Parents information Emergency contact
  information
• Insurance information
• Informed consent
• Release of medical records
• Release waiver of liability
• Evaluations, progress notes

• Assumption of risk
• Helmet liability release
• Heat acclimatization
• Treatments rehab forms
• Coachs reports
• http//www.ncaa.org/library/sports_sciences/sports
  _med_handbook/2005-06/2005-06_sports_medicine_hand
  book.pdf