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Information Management - Coggle Diagram
Information Management
Reasons for Documentation
Legal Protection
Memory Aid
Legal Requirements
Professional Standards
Improved Communication
Medical Records
patient specific
only information related to their health
Patient encounters to be documented at each visit
Easily and readily accessible
record keeping should be centralized
Problem Oriented Medical Record
past medical, social, and family history
S.O.A.P
Subjective (Most important , reflection of patients statements)
Objective (Physical data 2+ Lachman)
Assessment (judgement and professional opinion of problem)
Plan (emphasizes specific treatment interventions)
Medical Information Release
FERPA (Family Educational Rights and Privacy Act)
HIPAA (Health Insurance Portability and Accountability Act
Evaluation EMR'S
Security and Compliance
Ease of Use
Web Based
User fees and associated costs
customization potential
Reporting to Coaches
daily injury reports
recommendation for reduced activities
AT - Athlete relationship regarding non athletic injury
Preparticipation Agreement and Reporting of Injuries'