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Athletic Trainers' Practice Patterns Regarding Medical Documentation.

CONTEXT
Medical documentation is a required component of patient care in all health care professions.


OBJECTIVE
To evaluate athletic trainers' perceived behaviors toward, barriers to, and confidence in their medical documentation.


DESIGN
Cross-sectional study.


SETTING
Web-based survey.


PATIENTS OR OTHER PARTICIPANTS
We purchased a list of randomly selected e-mails from the National Athletic Trainers' Association. Of the 9578 participants, 1150 accessed our questionnaire (12.0% access rate), 1053 completed at least 1 portion, and 904 completed the questionnaire in its entirety (85.8% completion rate). Of the participants, 60.1% (n = 569/947) were female, 66.6% (n = 632/949) held a master's degree, 39.3% (n = 414/1053) worked in a collegiate or university setting, and 36.1% (n = 381/1053) worked in a secondary school setting.


MAIN OUTCOME MEASURE(S)
We used a 31-item questionnaire with demographics (12 items), medical documentation behaviors (16 items), barriers (2 items), and perceptions (1 multipart item) sections. The questionnaire explored athletic trainers' behaviors as well as confidence in, comfort with, and concerns about their documentation practices (Cronbach α = 0.887). We used descriptive statistics to identify characteristics of central tendency (mean, standard deviation, mode, frequency).


RESULTS
Participants always (45.7%, n = 478/1046) or very frequently (39.0%, n = 408/1046) used a double documentation system consisting of electronic and paper records (50.4%, n = 523/1038). They most often documented to provide legal protection (86.8%, n = 914/1053), because it is a legal obligation (79.1%, n = 833/1053), or to track patient progress (83.9%, n = 883/1053). The most frequently cited barriers to medical documentation were time (76.5%, n = 806/1053), managing too many patients (51.9%, n = 547/1053), technological concerns (17.2%, n = 181/1053), and software limitations (17.2%, n = 181/1053). Respondents believed they were competent, comfortable, and confident in their documentation practices.


CONCLUSIONS
We were able to evaluate the generalizability of previous research while adding to the understanding of the behaviors toward, barriers to, and perceptions about medical documentation. We confirmed that time and patient load affected the ability to perform high-quality medical documentation.

time of day when they document patient care. 1 Noting the criteria they used to determine the need to document an injury or illness, these secondary school ATs reported that they documented injuries and illnesses that required followup, more severe injuries, and time-loss or referred injuries. 1 These ATs indicated that a lack of quality, lack of professional or employer accountability, and perceptions that documentation is a lesser priority influenced their documentation practices. 5 Furthermore, they described inadequate facilities and a lack of time, adequate personnel, and accountability as primary barriers to producing highquality patient care documentation. 5 The perceptions that time and unclear expectations are barriers to medical documentation are not exclusive to athletic training. 3 Caregivers and clinicians employed in hospitals have reported spending more than 3 hours per day documenting patient care. 2 Physician residents and fellows have also reported that medical documentation requirements have a negative effect on the time spent with patients and the care they provide. 3 Moreover, facility and personnel shortcomings are commonly reported in athletic training as barriers to a number of responsibilities, including simply providing access to patient care or delivering consistent care based on staffing. 6,7 In addition to medical documentation being a required component of clinical practice in athletic training, 8 routine, high-quality documentation is necessary to legally record patient encounters, track patient progress, and evaluate the effectiveness of treatment interventions. Medical documentation can also yield valuable information regarding the athletic training services provided and the value of hiring an AT to provide patient care. Previous investigators 1,5,[9][10][11] in athletic training have provided robust qualitative analyses of practices in the secondary school setting, but little is known about medical documentation in other athletic training settings. Many of the reports from the Athletic Training Practice-Based Research Network have indicated a need for better medical documentation to facilitate analyses of practice behaviors, yet most of these were in the secondary school setting. Based on the available analyses conducted in the secondary school setting, we were able to develop a study to evaluate ATs' perceived behaviors toward, barriers to, and confidence in medical documentation in various clinical practice settings.

Design
We used a cross-sectional research design to evaluate the behaviors, perceived barriers, and perceived confidence of ATs in various settings using variable medical documentation systems. This investigation was deemed exempt research by the Indiana State University Institutional Review Board.

Participants
We recruited ATs who were members in good standing with the National Athletic Trainers' Association (NATA). Using the national membership directory, we purchased a list of randomly selected e-mail addresses of ATs who were certified, were US based, and worked in all types of settings. From the random sample of ATs, we sent 9578 e-mails to potential participants. Of the 1150 participants who accessed our questionnaire (12.0% access rate), 1053 completed at least 1 portion and 904 completed the questionnaire in its entirety (85.8% completion rate). Recruits provided informed consent by clicking ''I agree to participate'' and then navigated through the remainder of the questionnaire; they could withdraw or skip questions at any time.

Instruments
We used the results from previous qualitative studies 1,5,9 to develop a 31-item Web-based questionnaire (Qualtrics, Provo, UT). The questionnaire addressed demographics (12 items), medical documentation behaviors (16 items), perceived barriers (2 items), and perceptions regarding medical documentation (1 multipart item). To gain insight into the participants' perceptions, we asked them to rate their level of agreement with 7 statements about their, comfort, concerns, and confidence related to their medical documentation practices. These items were rated on a 5point Likert scale: strongly disagree (1), disagree (2), neither agree nor disagree (3), agree (4), and strongly agree (5).
To validate the survey, we called on a panel of experts (n ¼ 4; 3 women and 1 man) who have served as researchers and clinicians with expertise in medical documentation and survey development. The experts had 14 6 4 years of clinical experience, and 2 of the panelists had 11 6 1 years of survey research experience. Each expert completed a content-analysis rubric, which asked them to select whether each item needed revision or was sufficient as written. The experts provided comments to modify items that needed revision. We synthesized the feedback and changed the questionnaire where appropriate. After content validation, we conducted a pilot analysis with practicing ATs (n ¼ 25) to determine the internal consistency of the questionnaire, specifically regarding the perception items, and found it to be highly reliable (Cronbach a ¼ 0.887). The pilot sample consisted of ATs (age ¼ 29 6 7 years; 5 6

Procedures
We sent an initial e-mail on a Wednesday at 7:30 AM EDT to potential participants and then sent 4 reminders, each on a Wednesday at 7:30 AM EDT, to those who had not yet responded. Data collection remained open for 5 weeks during March and April 2017, closing 1 week and 2 days after the last reminder at 11:59 PM EDT. At the end of the data-collection period, we sent an e-mail to thank respondents who completed the questionnaire. The questionnaire took approximately 15 to 20 minutes to complete, and all data were stored in Qualtrics.

Statistical Analysis
We used descriptive statistics to identify characteristics of central tendency (mean, standard deviation, mode, frequency). It is common in survey research for participants to decide not to respond to specific items or to stop responding. This voluntary research involvement is a principle of the Belmont Report and is their right as participants. 12 However, partial data analysis is then required; because the missing data are not random, management techniques for missing data are not appropriate. 13 Partial data-analysis techniques are consistently used throughout the athletic training literature. 6,14
Respondents reported that they primarily documented patient care at the end of the day (28.7%, n ¼ 275/957) or after each patient encounter (27.7%, n ¼ 265/957). However, a sizable portion reported that they documented their patient encounters from the previous day at the beginning of the next day (6.3%, n ¼ 60/957) or only a few times a week (16.7%, n ¼ 160/957). Participants predominantly documented in the athletic training facility (43.4%, n ¼ 415/956) or in a secure office (41.9%, n ¼ 401/956).
Participants indicated that they documented for a variety of reasons, most frequently to provide legal protection (86.8%, n ¼ 914/1053), because it is a legal obligation (79.1%, n ¼ 833/1053), or to track patient progress (83.9%, n ¼ 883/1053; Figure 2). In contrast, they less frequently documented to demonstrate their value to stakeholders (32.1%, n ¼ 338/1053), communicate with parents (20.7%, n ¼ 218/1053), or bill for care or reimbursement (3.1%, n ¼ 33/1053). Respondents also observed that they documented injuries for a governing body (ie, National Collegiate Athletic Association, Major League Baseball, Occupational Safety and Health Administration) and to aid in team-based health care through written communication with students and other ATs in their facilities. When asked which aspects   Figure 4). We asked participants to choose the aspects of an initial evaluation, progress note, and discharge note they typically included in their medical documentation. A majority of participants reported the history of the present injury or illness (88.9%, n ¼ 936/1053), the tests and measures used during the examination (84.6%, n ¼ 891/1053), the diagnosis (80.7%, n ¼ 850/1053), and the patient's functional limitations (81.8%, n ¼ 861/1053; Figure 5). They did not often document evidence of clinician-rated (16.1%, n ¼ 170/1053) or patient-rated (15.7%, n ¼ 165/ 1053) outcomes. Some participants commented that they documented in a typical subjective, objective, assessment, plan (SOAP) note format and not following the example we offered, in which we used language for describing function, disability, and overall health (in alignment with the disablement model endorsed by the Strategic Alliance). 15 Others specified that ATs were not permitted to make a diagnosis but could give an impression in their documentation. In a progress or daily note, respondents described the interventions applied (82.2%, n ¼ 866/1053), any changes to the impairments or limitations and changes in participation status (77.6%, n ¼ 817/1053), and the future plan of care (73.9%, n ¼ 778/1053). They typically included responses to interventions (67.5%, n ¼ 711/1053) and communication with other health care providers (64.7%, n ¼ 681/1053) but were less likely to cite the factors influencing the frequency or intensity of the interventions applied (44.3%, n ¼ 467/1053). Again, they did not report documenting clinician-rated (26.0%, n ¼ 274) or patientrated (32.6%, n ¼ 343/1053) outcomes frequently but did so more often in progress or daily notes than in the initial evaluation. Almost half of participants did not write a formal discharge note when patient care ceased (47.7%, n ¼ 502/1053). For those who did write a discharge note, a statement of all the goals met (38.7%, n ¼ 408/1053) and further treatment recommendations (48.4%, n ¼ 510/1053) were provided. Fewer participants said they would include the interventions applied and the patient's responses to those treatments (32.9%, n ¼ 346/1053) as well as any impairments that might continue to limit the patient after discharge and the rationale as to why they still existed (31.6%, n ¼ 333/1053).
To protect patient health information, participants most often reported using password-protected computers (83.6%, n ¼ 880/1053), computer or software encryption (56.1%, n ¼ 591/1053), locked offices (72.9%, n ¼ 768/1053), and locked file cabinets (59.9%, n ¼ 631/1053). They did not typically use password protection on computer files or documents (21.3%, n ¼ 224/1053), locking mechanisms for medical documentation stations or computers (17.2%, n ¼ 181/1053), or virtual privacy networks to privately communicate with other providers (15.4%, n ¼ 162/1053). Some respondents used an in-house paper shredder (47.2%, n ¼ 497/1053), whereas others used an off-site paper shredder or a shredder operated by an external vendor (25.8%, n ¼ 272/1053). Although most participants indicated that their medical documentation was well protected, some said people without a right to know about    Participants largely agreed that they were competent, comfortable, and confident in their documentation practices. Furthermore, they had minimal concerns about the veracity of their medical documentation (Table 3).

Behaviors
Although previous research regarding athletic training documentation was limited, our findings were consistent with those of qualitative studies 1,5 examining secondary school ATs' perceptions of their patient care documentation. Similar to Nottingham et al, 1 our participants described documenting in several locations at different times of day and had similar reasons for documenting patient care, specifically providing legal protection and tracking patient progress. These findings suggest that ATs in different clinical settings exhibited similar documentation behaviors with respect to patient care.
Our respondents indicated that they rarely documented clinician-and patient-rated outcomes, which may be detrimental to quality patient care. Objective outcomes are important when justifying clinical decision making for treatment interventions, measuring treatment effectiveness, and ultimately, determining the quality of the care being provided. 16 Also, patient-rated outcomes are important to ensure patient perspectives on their health-related quality of life, functional ability, and recovery are taken into consideration. 17 Snyder Valier et al 18 examined ATs' benefits of and barriers to recording patient-rated outcomes during clinical practice and found that ATs perceived patient-rated outcomes as time consuming and difficult to complete. 18 Because most of our respondents reported that they did not record patient-rated outcomes, it appears that ATs may still be experiencing difficulty overcoming the perceived barriers to successfully implementing patientrated outcomes in their practice.
Medical documentation should involve electronic methods. 19,20 The American Recovery and Reinvestment Act incentivized the transition to electronic medical record keeping, part of which was designed to enforce best practices and laws for billing patient care. 20 Although ATs were not included in this legislation because we are not recognized by the Centers for Medicare & Medicaid Services as able to bill for patient care, the federal government requires electronic medical records in the medical community. Our participants indicated that they blended paper or pen and electronic documentation systems; only a third exclusively used an electronic medical record system. This suggests that ATs may not be up to date with contemporary documentation strategies or may lack adequate resources to use an electronic medical record system alone. As we transition to electronic medical record keeping, ATs need to improve data-security practices, specifically regarding health information technology, to protect ourselves and our patients.
Previous authors 10 who aimed to analyze daily encounters of ATs in the secondary school setting identified preventive care as the most common service provided but only for activities such as ankle taping or the application of a cold or hot pack. In our study, fewer than half of the participants commented that they would document preventive care. The earlier researchers 10 suggested that many preventive activities may not be directly related to documented patient care (eg, equipment fitting, field safety, practice modifications for environmental risks). However, other work 21 clearly showed that these are common practices among secondary school ATs. Only about 50% of respondents stated that they documented non-time-loss injuries, yet previous investigators 10,22 found that ATs spent substantial time treating patients with non-time-loss injuries. The reason may relate to the severity of the injury, whereby most daily encounters occurred for injuries that were not documented in the medical record. 10 Cumulatively, these findings suggest that we need to document both time-loss and non-time-loss injuries to better demonstrate our daily workload and value of the profession.
In terms of formatting medical documentation, many participants reported that they typically wrote patient records in the SOAP note format, which does not encapsulate principles of the disablement model or follow the ''Best Practice Guidelines for Athletic Training Documentation.'' 23 The World Health Organization International Classification of Functioning 16 asked ATs to consider not just the health condition itself but also to characterize the injury in terms of the body function and structures affected, the level of activity the patient is capable of performing, and any limitations to participation while taking into account environmental and personal factors that may affect the return to activity and function. Although it is certainly possible that a SOAP note can contain characteristics of the disablement model, the respondents seemed unfamiliar with the concepts of the latter.

Barriers
Similar to previous results 2, 3,5 in athletic training and other medical professions, our participants reported that time was a barrier to medical documentation. In studying ATs employed in the secondary school setting, Welch Bacon et al 5 determined that time and patient volume affected their ability to produce high-quality medical documentation. We found these were among the 2 most commonly cited barriers to medical documentation, regardless of setting, but they were also complicated by technology and software limitations. In addition, respondents described patient compliance as a barrier to medical documentation. The reference to patient compliance is interesting because ATs are obligated to document when patients have a change in status, 23 which should include when patients willingly discontinue care or are discharged from care. Instead of being a barrier to medical documentation, it is more likely a barrier that prevents ATs from providing high-quality patient care.
Participants were inconsistent in prioritizing medical documentation; no consensus existed regarding prioritization among their duties. However, among the approximately 40 hours of work dedicated to their jobs each week, respondents described spending an average of 6 hours documenting patient care. This equates to approximately 15% of time dedicated to medical documentation, which differs from the amount described by physicians (25%) and ATs working exclusively in the secondary school setting (10%-50%). 1,2,24 Presumably, the use of electronic medical documentation systems could improve efficiency. Almost half of the participants used both pen and paper and electronic medical documentation systems, creating redundancy, inefficiency, and potential security concerns. Considering these findings, it would be useful to explore  Our participants perceived themselves as competent, comfortable, and confident in their medical documentation practices. This result was different from that of the previous qualitative inquiry 5 : ATs in the secondary school setting suggested that the lack of relevant guidelines in athletic training led to uncertainty regarding what to document. Although the NATA recently released the ''Best Practice Guidelines for Athletic Training Documentation'' 23 (after our data collection), these guidelines do not provide specific expectations about what should be documented depending on the type of patient encounter, such as that provided in physical therapy guidelines. 25 Without specific guidance until recently, participants may not have known what was expected; therefore, they held high opinions of and appeared to be overestimating the quality of their documentation practices based solely on their professional preparation and socialization. For example, more than a quarter of participants stated that they failed to document severe injuries. It is not uncommon to overestimate knowledge in athletic training, thereby demonstrating a gap between perceptions and actual knowledge. [26][27][28][29] In this case, respondents had a high rating of perceived competence but reported behaviors that fell short of best practice.
More than 15% of participants agreed or strongly agreed that they had concerns that their medical documentation would not protect them in a court of law. This finding, in relation to the specific reported behaviors, is interesting. For example, only half of the participants stated that they would document non-time-loss injuries and just under 90% of participants would document a concussion. When legal statutes guarantee the primacy of the AT in protecting patients, particularly in concussion laws, 30 it behooves ATs to characterize patient care by documenting their work. The level of concern for legally defensible medical documentation is incongruous with actual practice behaviors.

Clinical Implications
Athletic trainers need to understand the importance of medical documentation for both delivering quality patient care and complying with the law. Our findings suggest that although the ATs felt confident in their documentation practices, most were not recording clinician-and patientrated outcomes, and many injuries and conditions were not documented at all. Additionally, many respondents' electronic documentation did not appear to be adequately protected according to their stated protected health information practices (eg, lack of locking mechanisms, individuals without a need to know having access to records). In a previous study, 9 ATs indicated they would like more continuing education opportunities on patient care documentation. Our results further suggest that ATs may benefit from additional training on what and how to document as well as why it is important to track patient progress in order to improve patient care. In particular, approved providers of continuing education should develop workshops with specific strategies for documenting different aspects of patient care in various environments and supply examples of quality documentation that can be used to enhance clinical practice. Offering examples of good documentation that would hold up in a court of law may also be useful to encourage high-quality medical documentation. 9 Beyond legal compliance, inconsistent medical documentation makes it difficult to characterize the athletic training services provided and impossible to determine the value and worth of ATs' clinical practice. Failing to document preventive services (eg, taping, stretching) or services related to non-time-loss injuries means that the time spent and unique services ATs provide during clinical practice are not captured. 10,11 Documenting each patient encounter can provide ATs with objective data that can be used to clearly outline the cost of the services provided and the savings for patients treated in the athletic training facility. The NATA's position improvement guides (value models) demonstrate how ATs can use these data to advocate for practice enhancements such as increased budgets, improved facilities, and additional athletic training staff. [31][32][33]

LIMITATIONS AND FUTURE DIRECTIONS
As with all survey research, self-selection bias is likely to occur. 34 As such, it is possible that our sample was more interested in the topic of medical documentation compared with nonresponders, thus influencing our results. Our participants demonstrated a slight sampling bias within the collegiate or university and secondary school settings. Clinic and clinic outreach ATs were not well represented in our sample.
Future researchers should evaluate the awareness of ATs regarding the NATA ''Best Practice Guidelines for Athletic Training Documentation'' 23 and compare their practices with those outlined in these guidelines. Intervention research aimed at educating practicing clinicians and programs aimed at reducing barriers and standardizing documentation platforms should also be evaluated.

CONCLUSIONS
We found that some medical conditions were more commonly documented (eg, concussion, patient referrals, heat exhaustion, glenohumeral dislocation, and grade 1 ankle sprain) and that practitioners believed that not all patient encounters rose to the level of requiring medical documentation. Most of our participants engaged in userlevel security practices to protect personal health information, but many of these protections were not system wide. Half of the participants indicated that the computers they worked on did not have encryption, which raises concern that medical documentation could be easily breached in today's cyber climate. We confirmed that time and patient load affected the ability to perform high-quality medical documentation. In this study, we found that respondents felt competent, comfortable, and confident in their medical documentation practices, contrasting with the results of previous researchers who noted that uncertainty and a lack of education were common themes. Athletic trainers need more exposure to best-practice guidelines and to continuing education and professional development opportunities to meet the expectations and performance of other health care providers.