Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

  Documenting patient care is an important responsibility of athletic trainers (ATs). However, little is known about ATs' reasons for documenting patient care and the mechanics of completing documentation tasks.

OBJECTIVE

  To understand ATs' perceptions about reasons for and the mechanics of patient care documentation.

DESIGN

  Qualitative study.

SETTING

  Individual telephone interviews with Athletic Training Practice-Based Research Network members.

PATIENTS OR OTHER PARTICIPANTS

  Ten ATs employed in the secondary school setting (age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) were recruited using a criterion-based sampling technique. Participants were Athletic Training Practice-Based Research Network members who used the Clinical Outcomes Research Education for Athletic Trainers electronic medical record system and practiced in 6 states.

DATA COLLECTION AND ANALYSIS

  We used the consensual qualitative research tradition. One investigator conducted individual telephone interviews with each participant. Data collection was considered complete after the research team determined that data saturation was reached. Interviews were transcribed verbatim and independently analyzed by 4 research team members following the process of open, axial, and selective coding. After independently categorizing interview responses into categories and themes, the members of the research team developed a consensus codebook, reanalyzed all interviews, and came to a final agreement on the findings. Trustworthiness was established through multiple-analyst triangulation and member checking.

RESULTS

  Participants identified 3 reasons for documenting patient care: communication, monitoring patient care, and legal implications. Four subcategories emerged from the mechanics-of-documentation theme: location, time of day, length of time, and criteria for documenting. The ATs described different criteria for documenting patient care, ranging from documenting every injury in the same manner to documenting time-loss and follow-up injuries differently.

CONCLUSIONS

  Whereas ATs recognized individual mechanisms that enabled them to document patient care, they may need more guidance on the appropriate criteria for documenting various patient care encounters and strategies to help them document more effectively.

Athletic Trainers' Perceptions of and Barriers to Patient Care Documentation: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

  For the practice characteristics of the services athletic trainers (ATs) provide to be identified, all ATs must complete high-quality patient care documentation. However, little is known about ATs' perceptions of patient care documentation or the potential barriers they may encounter while trying to ensure high-quality documentation.

OBJECTIVE

  To explore ATs' perceptions of and barriers to patient care documentation via the Clinical Outcomes Research Education for Athletic Trainers (CORE-AT) electronic medical record system in the secondary school setting.

DESIGN

  Qualitative study.

SETTING

  Individual telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

  We interviewed 10 ATs (4 men, 6 women; age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) who were members of the Athletic Training Practice-Based Research Network (AT-PBRN) and employed in the secondary school setting.

DATA COLLECTION AND ANALYSIS

  We conducted an individual interview with each participant. After transcription of the interviews, the data were analyzed into common themes and categories following the consensual qualitative research tradition. Data triangulation occurred through member checking and multiple researchers to ensure accuracy during data analysis.

RESULTS

  Participants revealed several perceptions of patient care documentation, consisting of quality, expectations and accountability, priority, incentive, and culture of the secondary school setting. In addition, we identified barriers to quality patient care documentation: lack of time, lack of accountability for documenting patient care, inadequate facility resources, and lack of personnel. Participants discussed the volume of patients as a unique challenge in the secondary school setting.

CONCLUSIONS

  Whereas ATs perceived patient care documentation as important, several practical barriers may inhibit their ability to complete high-quality documentation of the services they provide. Effective strategies to improve the quality of patient care documentation among ATs are needed to ensure that their value, particularly in the secondary school setting, is accurately characterized.