Context

Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training, leaving individual organizations responsible for setting expectations and enforcing policies. Previous research has examined clinician documentation behaviors; however, the supervisor’s role in creating policy and procedures, communicating expectations, and ensuring accountability has not been investigated.

Objective

To investigate supervisor practices regarding support, hindrance, and enforcement of medical documentation standards at an individual organization level.

Design

Mixed-methods study.

Setting

Online surveys and follow-up interviews.

Patients or Other Participants

We criterion sampled supervising athletic trainers (n = 1107) in National Collegiate Athletic Association member schools. The survey collected responses from 64 participants (age = 43 ± 11 years; years of experience as a supervisor = 12 ± 10; access rate = 9.6%; completion rate = 66.7%), and 12 (age = 35 ± 6 years; years of experience as a supervisor = 8 ± 5) participated in a follow-up interview.

Data Collection and Analysis

We used measures of central tendency to summarize survey data and the consensual qualitative research approach with a 3-person data analysis team and multiphase process to create a consensus codebook. We established trustworthiness using multiple-analyst triangulation, member checking, and internal and external auditing.

Results

Fewer than half of supervisors reported having formal written organization-level documentation policies (n = 45/93, 48%) and procedures (n = 32/93, 34%) and an expected timeline for completing documentation (n = 24/84, 29%). Participants described a framework relative to orienting new and existing employees, communicating policies and procedures, strategies for holding employees accountable, and identifying purpose. Limitations included lack of time, prioritization of other roles and responsibilities, and assumptions of prior training and record quality.

Conclusion

Despite a lack of clear policies, procedures, expectations, prioritization, and accountability strategies, supervisors still felt confident in their employees’ abilities to create complete and accurate records. This highlights a gap between supervisor and employee perceptions, as practicing athletic trainers have reported uncertainty regarding documentation practices in previous studies. Although supervisors perceive high confidence in their employees, clear organization standards, employer prioritization, and mechanisms for accountability surrounding documentation will result in improved patient care delivery, system outcomes, and legal compliance.

Key Points
  • Fewer than half of supervisors reported having formal written organization-level documentation policies, procedures, and time expectations for recording encounters.

  • Supervisors within individual organizations have a professional responsibility to create and enforce quality and accountability regarding medical documentation policies and procedures.

  • Prior training assumptions and lack of time are not justifications for allowing poor medical documentation, and supervisors must reorganize priorities to allow athletic trainers to dedicate time to documentation.

  • Supervisors can help support successful documentation practices by conducting individual quality improvement projects aimed at improving areas of weakness or by implementing interventions, such as annual training and education, individual meetings, frequent documentation review and auditing, and creating a unified purpose focused on continuity of care and advocacy for additional resources.

High-quality documentation and medical records are essential for evaluating effective and efficient patient care delivery and encounter experiences.1  Medical documentation can be used to track patient progress and help deepen a clinician’s understanding of the diagnosis and prognosis of an injury or illness or adopt new strategies in care management or record-keeping strategies.24  Medical recordkeeping is not without its limitations, as it can be tedious and time-consuming on top of other job responsibilities due to the data collection volume required and interface operation issues. Documentation strategies aligned with the Quadruple Aim of health care are known to reduce errors to improve population health, improve patient care effectiveness and experience, reduce costs on a per capita basis, and improve staff member and team well-being and productivity.5,6 

Although the National Athletic Trainers’ Association (NATA) has created best practice guidelines for documentation practices that emphasize professional responsibility and the advantages of appropriate documentation, such as risk mitigation, it does not provide explicit standards of practice.7  There are no nationally recognized standards or expectations for documentation mechanics or required inclusion criteria in athletic training.8  Research has shown that ambiguity in these policies and procedures may lead to gaps in records, inaccurate representations of athletic training services, and increased liability or decreased legal protection.9,10  There is also no standard operating procedure for conducting documentation reviews for quality assurance. Lack of accountability and clear expectations are significant contributors to documentation challenges.10 

Past research in medical documentation states the lack of employer expectations and accountability strategies, such as record auditing, may be connected to poor documentation practices and reduced priority.10  Part of the responsibilities of athletic training supervisors include communication of expectations and enforcement of policies and procedures, typically through enabling and modeling.11  Although the individual perspective on generating medical documentation is abundant in the literature,9,10,12,13  we have not yet explored how supervisors hinder, encourage, or enforce record-keeping standards. Our study intends to shift attention away from the individual provider and investigate the hierarchical approaches supervisors use to create standards and accountability for documentation practices. The purpose of this study is to investigate existing expectations, policies and procedures, and supervisory strategies related to facilitating medical documentation.

Research Design

We used a concurrent mixed-methods study approach using a combination of web-based surveys and follow-up interviews. This design allowed us to draw from the strengths and minimize the weaknesses of both qualitative and quantitative design types to contextualize the meaning behind the data.14,15  Using a mixed-methods approach, we took the quantitative data of the survey and amplified the values using the voiced collective experience of current supervisors. The targeted approach allowed us to elaborate and uncover areas of content not represented in the use of 1 tool alone.16  Before data collection, the risks and benefits of the study were explained to all potential participants, and they provided consent to participate. The Indiana State University Institutional Review Board deemed our study exempt.

Participants and Setting

We created an internal database of supervising collegiate and university athletic trainers (ATs) and their emails (N = 1107) in Divisions I, II, and III of the National Collegiate Athletic Association (NCAA) using publicly available webpages. Using the publicly available contact information, we selected individuals with titles such as head AT, director, manager, supervisor, or coordinator or individuals who otherwise indicated they oversaw the services of other ATs and sent emails through Qualtrics software (Qualtrics LLC). Of the 1107 possible participants, 106 accessed the online survey (9.58%), 5 reported they were not supervisors, and 5 did not consent. Of the 96 individuals who identified as eligible supervisors and consented to participate, 64 (66.7%) completed the survey in its entirety (survey participants’ age = 43 ± 11 years; years of experience as an AT = 21 ± 10; years of experience as a supervisor = 12 ± 10). Twelve participants elected to participate in the follow-up interview (age = 35 ± 6 years; years of experience as an AT = 14 ± 5; years of experience as a supervisor = 8 ± 5). Table 1 describes the survey demographic characteristics of all participants, and Table 2 depicts specific characteristics of the interview participants.

Table 1.

Survey Demographics (n = 64)

Survey Demographics (n = 64)
Survey Demographics (n = 64)
Table 2.

Interview Demographics (n = 12)

Interview Demographics (n = 12)
Interview Demographics (n = 12)

Instrumentation

Our research team created a 24-item survey instrument based on the study’s specific aims using a variation of close-ended Likert-scale questions and open-ended questions. We developed questions deductively based on findings from previous literature on documentation practices in athletic training.9,10,12,13  We asked these participants to answer questions regarding their expectations, organizational policies and procedures, and strategies to encourage their staff to produce high-quality medical documentation. The questionnaire addressed 1 screening item; demographic items (9); medical documentation policy, preparation, and expectations (11); perception of employee competence (2); and interest in participating in a follow-up survey (1). We measured employee competence by asking for perceived confidence in policy and procedure clarity, thoroughness, and confidence in employee ability to generate complete and accurate patient care documentation. Employee competence and clarity and thoroughness were measured on a 6-point Likert scale: strongly disagree (1), disagree (2), slightly disagree (3), slightly agree (4), agree (5), and strongly agree (6).

We validated the survey using a content validity index process as described by Polit and Beck.17  We sent the survey to a panel of 5 content and/or methods experts in survey creation, medical documentation, and/or supervision of ATs. We instructed each expert to complete a content analysis rubric for the survey, with options to select Needs Revision or Sufficient as Written and a space for additional comments to address either category. The rubric used a numeric scale to rate the relevance and clarity of each item rating, including not relevant (1), item needs some revision (2), relevant but needs minor revision (3), and very relevant (4). These values were then averaged to create a total relevance and clarity score. To deem the survey valid, we required each item to have a mean agreement of 75% for relevance and clarity. We analyzed and synthesized all feedback and required no additional rounds of review. No items needed revision or removal from the tool. The tool’s scale-level content validity index score is 0.93, demonstrating excellent content validity.18 

We used semistructured interviews to gather additional insight into the effectiveness of communication, dissemination of information, and quality of existing policies and procedures based on the quantitative information collected in the survey. The research team created an interview protocol with 7 primary questions and potential follow-up questions based on the study’s specific aims and past literature using the same process described above.10  Two individuals with experience in qualitative research and medical documentation reviewed the interview script for face validity. The interview protocol required no additional revisions. The primary investigator practiced the interview with 3 eligible individuals to assess timing and question sequencing; their data were not included in the analysis. Table 3 describes the questions used in the interview.

Table 3.

Semistructured Interview Protocola

Semistructured Interview Protocola
Semistructured Interview Protocola

Procedures

Our study used email recruitment methods to garner participants. We sent initial emails to all potential participants, including the study’s purpose and a survey link. We sent reminder emails weekly during the 6-week data collection period. Once participants indicated consent, they spent approximately 28 minutes completing the survey. We secured all survey responses within Qualtrics and deidentified them before downloading and saving them to a secure cloud storage site.

The last question on the survey provided participants the opportunity to indicate interest in participating in a follow-up interview. Participants who indicated interest were directed to an additional survey to submit their contact information. The principal investigator (PI) conducted all interviews, and they lasted, on average, 25 minutes. After each interview, the PI saved the deidentified transcript and audio file, using a pseudonym, to a secure cloud storage site. We sent participants a copy of their transcribed interview to ensure accuracy and instructed them to clarify and address potential concerns within 14 days. If participants did not respond within 14 days, we used their original transcripts for analysis. Only 1 participant responded requesting minor copyedits. Saturation was achieved when the PI no longer heard new core ideas during interviews. The data analysis team (3 members of the overall research team) discussed field notes and PI observations before concluding that data saturation had been achieved.

Data Analysis, Researcher Reflexivity, and Trustworthiness

We used descriptive statistics to examine demographic variables, including participant age, university setting, years of experience as a certified AT, years of experience as a supervisor, and the number of staff under supervision for the survey and follow-up interview.

Incomplete data sets are common in survey research, as this research is voluntary, and discontinued participation is the participant’s right, as stated in the Belmont report.19  Because the number of respondents varied per question, we used partial data analysis techniques to manage missing data.20  These techniques are used throughout the literature to account for potential bias and the lack of randomness with missing data.13,21  We set the significance level a priori at P < .05. We analyzed all quantitative data using SPSS (version 27; IBM Corp).

We used the consensual qualitative research tradition to develop codes from the interview transcripts due to its previous use in athletic training research and medical documentation and its aptitude for in-depth analysis.10,22,23  The data analysis team consisted of 3 individuals (J.S.D., M.J.D., L.E.E.) who ranged from novices to experts in the consensual qualitative research tradition. The 4-step process began with an inductive approach, reviewing the first 5 transcripts.22  After, each member of the data analysis team independently reviewed these transcripts to create a domain list reflective of the data.22  The data analysis team then met and developed an initial codebook with domains and categories.22  The codebook was then applied to 2 of the original transcripts and 3 new transcripts to ensure an accurate representation of ideas.22  The data analysis team met again to confirm that the original codebook was still accurate.22  After, the PI applied the consensus codebook to all the transcripts.22  The research team met for a final time to confirm that the codes were applied correctly across all transcripts. The PI then created a cross-analysis of all participant interviews.22  The research team used the cross-analysis to ensure that all quotes under each domain and category had no outliers and that the placement of the quotes within each category was appropriate.22 

After completing all steps, the data analysis team sent the interview script, consensus codebook, cross-analysis report, and coded transcripts to an external auditor (E.R.N.) to explore blind spots or selective perceptions or biases of the data analysis team during the coding process.22  We made no changes from the review. Triangulation of the data was ensured by comparing the domains from the qualitative data with the quantitative data of the survey to examine similarities and create a comprehensive representation of the results. Research reflexivity is an expected factor in qualitative research. The PI acknowledges the potential impact of their previous experiences, assumptions, and beliefs in medical documentation while conducting interviews.24  We established trustworthiness by using multiple-analyst triangulation, member checking, and internal and external auditing.

Participants supervised an average number of 6 ± 5 employees and provided services for 442 ± 172 patients in the collegiate setting. The range of employment settings varied across divisions: Division I (n = 20/64, 31.3%), Division II (n = 16/64, 25%), and Division III (n = 28/64, 43.7%). The supervisors reported being certified by the Board of Certification for 20 ± 11 years. Supervisors carried various titles, from head AT (n = 43/64, 67%), director (n =15/64, 23%), athletic director (n = 2/64, 3%), AT (n = 1/64, 2%), associate director (n = 1/64, 2%), AT/health care administrator (n = 1/64, 2%), and both lead and head AT (n = 1/64, 2%).

Fewer than half of supervisors reported having formal written organizational documentation policies (n = 45/93, 48%), procedures (n = 32/93, 34%), and time expectations for recording patient encounters (n = 24/84, 29%). The time expected to complete documentation ranged from no expectations to 90 days from the incident. The 22 open-ended responses from the survey included as soon as possible (n = 1, 4.5%), within 24 hours (n = 7, 31.8%), within 36 hours (n = 1, 4.5%), within 48 hours (n = 4, 18.2%), within 72 hours (n = 1, 4.5%), within 96 hours (n = 1, 4.5%), within 1 week (n = 3, 13.6%), within 2 weeks (n = 1, 4.5%), within 30 days (n = 1, 4.5%), and within 90 days (n = 1, 4.5%). Supervisors noted that their employees documented on paper (n = 2, 3%), electronically (n = 31, 48.5%), and a mix between paper and electronic (n = 31, 48.5%).

Most supervisors agreed (33%, n = 23) or slightly agreed (33%, n = 23) that their documentation policies and procedures demonstrated clarity and thoroughness. Most supervisors also agreed (51%, n = 69) that they were confident in their employees’ abilities to generate accurate records (Table 4). A majority of the supervisors (62%, n = 38) noted having a section in the orientation specific to documentation standards. The items supervisors required employees to include in evaluation and treatment notes were variable (Tables 5 and 6).

Table 4.

Supervisor Perceptions (N = 69)

Supervisor Perceptions (N = 69)
Supervisor Perceptions (N = 69)
Table 5.

Evaluation Note Criteria From Survey (N = 78)a

Evaluation Note Criteria From Survey (N = 78)a
Evaluation Note Criteria From Survey (N = 78)a
Table 6.

Treatment Note Criteria From Survey (N = 64)a

Treatment Note Criteria From Survey (N = 64)a
Treatment Note Criteria From Survey (N = 64)a

Qualitative interview data revealed 2 domains related to supervisor practices regarding medical documentation in the collegiate setting: (1) framework and (2) limitations. Categories within the framework domain include training, expectations, accountability, and purpose. Categories within the limitations domain include deprioritization and assumptions, with prior training and quality as subcategories. The frequency of participant cases per category is displayed in Table 7.

Table 7.

Codebook Frequency Counts

Codebook Frequency Counts
Codebook Frequency Counts

Framework

Participants described having a philosophy around orienting new and existing employees, communicating policies and procedures, holding employees accountable by using different strategies, and identifying a clear purpose that served as a framework to organize their staff development. Approaches that supported successful documentation practices included annual training/development and education, individual meetings, frequent documentation auditing or review, and an emphasis on continuity of care and advocacy for additional resources.

Proactive Development

Proactive development for organizational documentation practices occurred upon immediate hiring in orientation, during annual training, and yearly, demonstrating a commitment to continued improvement. Participant 2 described conducting a yearly brainstorming session each summer to adjust documentation strategies, followed by an intensive learning experience for all staff:

We do a lunch and learn where we go over exactly how we want everyone to document all the things that we’re documenting…So, we have a whole afternoon going over what’s expected and how it’s supposed to be documented. And then typically we asked that the first couple injuries…to do that with me or another staff member who’s done it before, so we can see how they go about clearing the documentation…We also do simulated ones…And then their schedule has to have documentation time built into it. So that’s a way that we know that people are working on it every day…we have a minimum of an hour of documentation time, but they can break that up if they want to.

Other supervisors mentioned software tutorials, reviewing the NATA Best Practice Guidelines,7 describing expectations for the completion of different forms, reviewing policies and procedures, and encouraging check-ins or asking questions as needed. Participant 3 noted that after the initial training, further training can extend as long as “6 months or a year to make sure they understand everything.” Overall, the supervisors emphasized a need for both intentionality around periodic training and the ongoing nature of that training to ensure that staff were actively working to improve documentation practices.

Explicit Expectations

Supervisors discussed a plethora of documentation expectations they had for their staff. Often, supervisors communicated their expectations most clearly during orientation and onboarding sessions, but this was just the vehicle for communicating expectations. Expectations were communicated orally and in writing via policies, procedures, and examples of quality records. Participant expectations for timing to complete documentation were variable, similar to the survey responses. For example, participant 1 expected encounters to be documented before leaving the office for the day, but participant 11’s expectations were far less stringent: “I think the expectations are that it’s done, it’s being done. I don’t have a lot of firm expectations as far as how or when.”

Participants also discussed specific criteria for creating notes and inclusion criteria within the notes. Participant 12 described the difference between an encounter that would be documented and one that would not be documented:

So, we track pretty much everything that comes through. That does include every ice bag for example. I will say that if an athlete comes in and it’s just like, “I just need a Band-Aid and I need nothing else,” we don’t track that. But if it’s, “I need a band aid, but I need it cleaned,” that is counted as a patient encounter. For us, we consider it an encounter 99% of the time if an athlete comes in and goes out with some kind of assistance.

Although some supervisors only expected standard information within a note using the subjective, objective, assessment, and plan format, others had more specific criteria. Participant 8 stated,

High-quality documentation that looks like you’re getting a very good idea of that patient themselves, including their goals, their own personal goals, and then to have a very good objective section where you’re clearly able to rule in and out conditions. And then be able to provide both the clinical exam, or a clinical assessment, and what the patient’s impairments are, and all that culminating with an overall care plan that has timelines, discharge criteria, ideas for modalities, and what the direction of the rehabilitation looks like. But those goals should definitely reflect the patient’s goals, and then all of the daily notes that go along with that should all touch on the initial care plan, and if there’s modifications or anything like that. That’s what that should look like. So, it should be just a very, “wow this is very continuous, clearly there’s an obvious direction that the patient is going in.” And patient outcome measures should also be included in that.

Enforcement of Accountability

The accountability category encompasses the continuum of engagement from the supervisor, ranging from specific and intentional strategies to little-to-no involvement. For instance, participant 2 reported,

I have a weekly check. They know that every Tuesday I go in and I can check all of our open injuries and make sure that they have follow up notes or that they’re actually in the software system…So we do those checks and then again at the end of the month, we do reports that show kind of productivity and so they’re held accountable for that as well.

Other strategies for ensuring accountability included reviewing spreadsheets generated by the electronic medical record (EMR) and emailing reminders to staff to update or close injury cases. Participant 5 noted,

Through Excel reports that I can generate with our EMR, I can view [for example] how many injuries do we have in any given year, how long have they been open, and how long has it been since they’ve been updated. Periodically throughout the year I will send an email with “we have X injuries that have gone more than 2 weeks without an update. If they need it, please update them. If they are in fact closed, please go through the process of closing them so we don’t have open injuries that don’t need to be open.”

Participant 7 described spending more time during the orientation process to explain documentation expectations for part-time employees to ensure accountability. When these employees do not meet these expectations, there is a process for attempting to identify the source of the problem and offer immediate and long-term solutions. They described the process.

First, we asked them, “Was there a problem? Were you confused? Did you not know that you needed to meet this expectation?” And we look for their response and then we kind of go from there. If it’s repetitive, then we sit down with them and we say, “We really expect this to be filled out completely in this manner…” But in the past, if we’ve seen someone that just really, just isn’t getting it…someone, that is just really just not getting the job done, then we decrease their hours or eventually phase them out of working with us.

Participant 11 noted that he does not have any strategies to hold his employees accountable.

To require a certain format of documentation or a certain content to documentation takes away a little bit of an individual’s autonomy and their kind of personal style of documenting their encounters. I’m also not a huge fan of putting in place policies or rules that don’t have any enforcement behind them. And I’m not entirely sure how I would go about enforcing a documentation policy, or even if I want to, to be honest. Because the idea that I would have to fire an AT because their notes weren’t up to a standard that we created, I’m having a hard enough time finding ATs as it is. So, we’re trying to work with kind of what we’ve got and meet people where they’re at as far as their abilities and their desires and their own personal style.

Intentionality

Supervisors noted the purpose of documenting fell into 1 of 4 categories: continuity of care and delivery, communication, “cover yourself” and legal implications, and value demonstration. Participant 12 credits her previous training in emergency services, where she follows the sentiment of “if you didn’t write it down, you didn’t do it.” In addition to helping with advocating for pay or budget increases, she stated,

…It helps with accountability and helping us communicate with coaches, it helps us communicate with stakeholders just what we are worth, and what we need to continue to be successful and also a bit of CYA [cover your assets]. Make sure that if something were to happen, we are covered. But also it’s if I’m covering for someone, or someone is covering for me, and they are working with one of my athletes and they don’t know the whole case, they can go in, read that [evaluation], and have a sense of what’s going on so they can better help with the transition of care between myself and the temporary person.

Participant 6 noted that high-quality documentation is required for his employees to be reimbursed and also for interprofessional collaboration.

…It also just strengthens the need for a really good working relationship with your team physician because they’re ultimately signing off on these injuries, a lot of times without actually evaluating them in person, just agreeing that the plan of care is a reasonable plan of care.

Limitations

The limitations domain included organizational concepts relative to barriers in creating high-quality documentation.

Deprioritization

Supervisors often described documentation as one of many responsibilities, noting that high patient volume and few staff sometimes limited their ability to create high-quality documentation. Two supervisors noted prioritizing seeing more patients over documentation. Participant 8 indicated,

We have 470 athletes here at the institution that I work at, and we have the equivalent of 3 ATs. And so, to have so few ATs for that many athletes, to sit down and write a full note like that, it takes a lot of time. You think, I could be seeing so many more athletes during that time.

Participant 10 reported empathizing with his staff being busy and not wanting to enforce more strict expectations due to high demands of delivering patient care and covering events.

I’m very confident that they’re on the same page with how we want to document, how we want to treat, how to do things, but there’s just external factors in the way that we feel are limiting that in some ways.

He recognized that high-quality documentation includes a comprehensive evaluation and treatment notes but also recognized the demands placed on staff. He described a need for leniency until workloads decrease, more staff is hired, or other external demands change. He said,

I’m not a very mean supervisor…A lot of it is in just reminding them…But I’ve never had to discipline anybody for not doing it…We had 2 people…gone for 35 days out of a 55-day span…that’s an unbelievable amount of travel…their documentation during that time was not awesome. It was just how busy it was. So, we talked to them, like, “I know you’re busy. Get done what you can.”

Participant 11 noted that the additional responsibility of creating a policy and procedure and enforcing it from a supervisor’s perspective was not high on his priority list. He noted that not setting a firm guideline or expectation but still expecting it to be done regularly is a “good middle ground.”

I think supervisors have to choose how they want to spend their energy so that we don’t get burned out…So, it’s kind of picking your poison. Am I going to spend an extra 2 hours at work meeting the standards of documentation, and then feel like I’m burnt out that way and kind of creating my own problems?

Assumptions of Prior Training and Quality

The supervisors described their belief that their staff possessed adequate training before hiring and produced high-quality documentation despite supervisors failing to review or audit existing records. Participant 3 attributed prior training to years of experience, stating, “I think for somebody who’s been out 10 plus years, they’re given the list and I probably just expect it. They haven’t gotten any extra training, other than on the EMR.”

Participant 6 commented on the expectation of all ATs.

I just assumed that when I get somebody who’s a certified AT, especially somebody who comes recommended to me by a trusted individual, that they know how to do the job and it’s more to me about personality and relationship building than anything else.

Participant 7 noted that although she does review documentation, she does not use a tool or checklist. Instead, she looks for standard criteria, such as status, progress, and goals, to determine quality. When asked why she does not have more strict accountability measures, she reported,

I think we’ve got great employees. I think they work really hard. I think we probably overlook a lot of the documentation loopholes. If we can discuss with them, we’ll fill in the blanks and add addendums more. As long as we make sure that they’re actually treating the athletes appropriately.

Participant 9 further echoed this sentiment of not feeling the need to have accountability strategies in place, stating, “I’m really lucky with the staff that we have because they’re all very, in my opinion, very thorough and professional and on time with their notes that they do.”

Reasons, Criteria, and Mechanics

The Strategic Alliance’s Athletic Training Research Agenda was developed to improve patient care and advance the profession, and improving medical documentation compliance and quality is listed within the Health Information Technology priority.25  Research regarding athletic training medical documentation continues to grow. In our study, the reasons supervisors cited for creating medical records, selecting criteria for which encounters to record, and choosing mechanisms for documenting were consistent with past literature,8,9,13  highlighting a similar level of understanding between the ATs functioning as employees and those functioning in supervisory roles. These reasons included continuity of care and delivery, communication, “cover yourself” and legal implications, and demonstrating value. Despite similar levels of understanding between supervisors and employees, the findings from our study imply that the execution of enforcing quality documentation practices is variable between different organizations.

Policy and Procedure Creation

The NATA Best Practice Guidelines serve as a reference for the importance of documentation, key terminology, understanding of local and federal rules and regulations, and setting-specific considerations.7  These guidelines do not dictate specific standards for documentation mechanics, inclusion criteria, timeliness, or accountability expectations. It is worth noting that the lack of standardization does allow ATs to be flexible in creating policies and procedures that meet local organization needs. The solution to inadequate medical documentation in athletic training may not be complete standardization but more specific guidelines and encouragement for individual organizations to take responsibility and ownership in creating and upholding their own policies and procedures.

In our study, no supervisors commented on consulting with legal counsel when creating their policies and procedures regarding medical documentation. Individuals described professional education and socialization, life and clinical experience, trial and error, and quality improvement (QI) projects as sources for developing policies. Supervisors should coordinate with risk management experts when crafting policies and procedures for emergencies and daily operations because unexpected or unwanted outcomes may lead to litigation if an appropriate process is not in place.26,27 

Our study showed similar results as those reported in previous studies28,29  regarding the lower prevalence of formal policies and procedures, with fewer than half of supervisors reporting having formal written organizational documentation policies, procedures, and time expectations for recording encounters. One study examined written and nonwritten organizational practices and reported that only half of the secondary school ATs were using risk management practices to write their policies and procedures.28  Another study found that policies and procedures regarding administrative responsibilities, including medical documentation, were operational and written only 64.3% of the time; 20.8% indicated that they were operational only, 0.9% noted that they were written only, and 14.0% indicated that they were neither written nor operational.29  They also found that only 35.3% of collegiate ATs had guidelines for periodically reviewing their policies and procedures.29  Potential strategies for improving policy and procedure knowledge retention and enforcement include developing clear and concise expectations and instructions and reviewing materials at least annually and as often as necessary.30 

Accountability, Education, and Training

In addition to considering risk management when creating policies and procedures, health care departments should also consider managerial, organizational, and clinical approaches to investigate multiple perspectives on service effectiveness and efficiency. Known as clinical governance, this approach provides a framework that encourages cohesiveness among all personnel for achieving goals related to improving quality and patient care safety in a way that is practically manageable for supervisors and executable by employees.31  An example of this type of project in previous literature included using patient-rated outcome measures to assess the impact of health care interventions on patients and guide resource allocation.32  The cohesiveness of clinical governance can help ensure systemic dissemination of concepts, timely interventions for performance gaps, and consistent standardization in record quality.33  To address poor performance, individuals must communicate feedback with clear expectations to support the rationale. Directness creates the basis for accountability, which is essential for organizational change and transformation. Past research supports 6 elements for supervisors in health care to implement successful change: a compelling vision with a sense of urgency, meaningful and realistic plans understood by stakeholders and employees, teamwork and empowerment, effective 2-way communication, expanding on previous success to create momentum, and strong and effective leadership.34,35 

Accountability and lack of accountability were significant findings within our results as well as previous research in medical documentation practices in athletic training.10,13  Evidence from our study identified accountability strategies that included annual training and education, weekly injury report checks, 1-on-1 meetings, and medical documentation review and auditing. However, some evidence suggests that employees may need more than resources, periodic tips, and refreshers to inspire sustainable improvement.8  Various tools have been used among health care professionals to inspire such improvement, and these tools often need to reflect the profession’s and organization’s services and responsibilities. For example, self-audits and peer audits effectively improve documentation quality.36,37  Although these internal audits may be an effective way to engage staff in mutual accountability, clinical auditing must be completed with a high level of knowledge on accuracy, availability, completeness, relevance, reliability, timeliness, and validity to produce higher-quality medical records.37  Supervisors should consider exploring different auditing strategies and selecting interventions based on the individual organization’s needs, building the process into their documentation policies and procedures to enforce standards and expectations.

Implementation of the new Commission on Accreditation of Athletic Training Education professional program Curricular Content Standards around QI and health care informatics essentially demands improved education and exposure during professional preparation and can serve to improve documentation practices across the profession.38  Recent literature suggests that academic electronic health record systems may assist in training athletic training students. These systems use activities such as educational tasks, documentation projects, critical reviews of standardized patient cases, and assessments of patient care data for QI efforts to improve competency in informatics and documentation skills.39  Moreover, these practices also offer an opportunity to evaluate practice and improve patient safety, and engaging in these learning activities when preparing future ATs will likely improve the skills of documenting and the culture around documentation in the coming years.

Prioritization

Athletic training literature has referenced lack of time as a barrier for a multitude of practice behaviors, including medical documentation.10  Our study echoed these sentiments, specifically with medical documentation, as previous research has suggested that it is not a lack of time but a lack of priority, a lack of knowledge, and a lack of incentive.9,10  The rationale of prioritizing patient care and supporting high caseloads or event coverage is echoed in our study alongside other athletic training medical documentation studies.8,10,13  Other health care professions are often beholden to insurance companies and the Centers for Medicare and Medicaid Services; to get paid, one must document.40  It may be because of the historic nature of athletic training as a cost-containment effort41  that the athletic training profession has failed to incentivize documentation, but it is truly indiscernible when and where the shift in deprioritizing documentation occurred in athletic training. Although medical documentation is required for clinical practice in health care, many athletic training organizations are still falling short.

Evidence from our study and past research may suggest that the common culture of athletic training places patient care and constant availability above all else, disrupting the necessary time and energy to dedicate to other roles and responsibilities. It is evident that a cultural shift is needed to comply with best practices in order to optimize time and reduce medical errors for legal and patient safety reasons. High-quality documentation ensures the completion of many essential components of care. These components include, but are not limited to, a comprehensive evaluation, consideration of differential diagnoses, timely and appropriate treatment of potential or active life-threatening conditions, and creation of clear care plans noting follow-up testing and referral to other providers as needed. A choice to prioritize other roles and responsibilities above medical documentation is a choice, albeit not an intentionally malicious choice, to deprioritize patient safety.

Limitations and Future Directions

Although survey research can reach many participants, there is a risk for self-selection bias42  and sampling bias because we only surveyed ATs working as supervisors within NCAA-affiliated schools. Our population sample may have been more open to talking about their documentation practices and thus could influence the generalizability of the results. Our lower response rate could also be attributed to this limitation, as 95% completed the survey through demographics, but only 68% completed the tool in its entirety.

Future intervention research in medical documentation should evaluate the effectiveness of different strategies for improving the overall quality of documentation and frequency of documentation completion. Further studies could take the form of research commentary or implementation science, such as QI projects.43,44  Quality improvement projects might illuminate the process of creating policies and procedures or explore the process of improving medical documentation locally. Potential areas of improvement might include enhancing discharge45  and diagnosis46  processes, item inclusion criteria,47,48  and holistic care approaches.49  Additional research could also evaluate the differences and similarities between documentation practices across other health care professions, levels of education, and training completed to meet organizational standards and foster interprofessional collaboration and communication.

Despite supervisors acknowledging the various purposes for completing documentation and the importance of high-quality records, currently, there are no consistent strategies for ensuring employee accountability and quality of content within records. In place of a nationally recognized standard for documentation inclusion criteria and mechanics, individual organizations are encouraged to use risk management personnel and other essential stakeholders to create appropriate and sound policies and procedures for the roles and responsibilities of the employees working in the environment. Expectations regarding format, process, and content should be clear and executed among all employees. Until the governing bodies can make further recommendations, supervisors should use QI strategies to identify gaps within their organizations’ documentation methods and strategize approaches that support employee prioritization of promptly producing complete and accurate documentation. Clear organizational standards and reinforcement of employer accountability will assist with QI efforts targeting improved patient care delivery, system outcomes, and legal compliance.

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