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Keywords

Health Care Competency, Vitality of The Profession, Information Technology

Abstract

Documentation is a professional standard for all health care professions. As part of a relatively young profession, athletic trainers have had to adjust to the expectations around documentation to stay at the same level as other health care providers. Documentation is often a highly discussed topic with more and more education sessions and resources being provided by NATA, BOC and NATA Research Education Foundation. The need for Continuous Quality Improvement projects and subsequent studies has continued to grow. Projects with a focus on documentation can be completed then disseminated to determine the most effective ways to improve documentation across our profession. At the university used in this project, members of the sports medicine staff were made aware of a lack of consistency in documentation quantity and quality. The purposes of documentation are patient care, communication, and ethical-legal requirements. To further evaluate the state of documentation by the sports medicine staff a quality improvement plan was launched in November 2021. Through three Plan Do Study Act (PDSA) cycles the documentation practices were improved over a 14-month time frame. In the PDSA 1, the staff increased the number of documentation notes in a year-to-year comparison by 2652 notes. The total number PRO outcome collected increased through the second PDSA. The quality of the notes improved by 2 points on a 5-point scale during the third PDSA process.

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