athletic trainers' perceptions of and barriers to patient care documentation: a report from

What do ATs need to document?

Athletic training organizations require ATs to document patient care , 2−4,29 but aside from general recommendations of what to include, most documentation is left to the discretion of the AT. This is likely the primary reason why our participants perceived few to no expectations and little accountability for patient care documentation and also indicated uncertainty about what to document as a barrier to their patient care documentation. 16 The guidelines for documentation in athletic training are less detailed than those for other professions, such as physical therapy, which provides specific categories for types of patient encounters and what should be documented in each encounter. 30 Other health care professions also rely more heavily on Centers for Medicare and Medicaid Services 1 guidelines to meet eligibility for reimbursement. Guidelines available for ATs are more general, 2 possibly leading to confusion about when and which patient care encounters should be documented. Athletic training may benefit from providing more specific standards for patient care documentation, which could be used to educate ATs at both the professional and continuing education levels. Without more specific guidelines, however, ATs will likely continue to pursue individual approaches to patient care documentation.

Do athletic trainers have to provide documentation?

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.