Patient Care Documentation in the Secondary School Setting: Unique Challenges and Needs

Area of Science:

• Sports Medicine
• Health Informatics

Background:

• Athletic trainers (ATs) consider patient care documentation vital.
• Previous studies highlighted time and accountability issues with one electronic medical record (EMR) system.
• Documentation behaviors across different systems (paper, EMR, hybrid) were unclear.

Purpose of the Study:

• To investigate the documentation behaviors of ATs.
• To identify perceived challenges in patient care documentation.
• To explore these factors within the secondary school setting across various documentation systems.

Main Methods:

• A qualitative study employing individual telephone interviews.
• Twenty ATs from diverse National Athletic Trainers' Association districts participated.
• Data were analyzed using consensual qualitative research traditions, including independent coding and triangulation.

Main Results:

• Lack of time, high patient volume, and multiple care locations were key challenges.
• These challenges influenced documentation decisions regarding process, content, and timing.
• ATs expressed a need for enhanced professional development, resources, and guidelines.

Conclusions:

• Secondary school setting challenges impact ATs' documentation behaviors irrespective of the system used.
• Targeted professional development is essential to foster optimal patient care documentation practices.