Instructions for Athlete Injury/Illness Management in Injury Zone

Transcription

1 Virginia Tech Departmental Policy 37 Sports Medicine Key Function: Review: Yearly Title: PresagiaSports On-line Injury Tracking System S-A Safety Director of Athletic Training Section: POLICY STATEMENT: This policy insures and communicates complete and comprehensive procedures for illness/injury tracking from onset through resolution. PURPOSE: To provide and communicate to sports medicine staff with regards to each individual s responsibility during the initial entry, dictation and transcription phases of student athletes illnesses/injuries. ENTITIES TO WHOM THIS POLICY APPLIES: Virginia Tech Sports Medicine Staff including Certified Athletic Trainers, Athletic Training Students, Physicians and Administrative Assistants. PROCEDURE: Section One. Instructions for Athlete Injury/Illness Management in Presagia Sports Instructions for Athlete Injury/Illness Management in Injury Zone I. Directions for ATC s A. New Injury 1) Type in athlete s last name and select the correct athlete (if an athlete is not in the system, be sure to add them and enter all of the applicable information) 2) For a new injury, select New and then Injury or Illness 3) Fill in the body part, side and type of injury (leave the code blank for now) 4) Fill in the remaining fields 5) Under Injury Notes, select ATC Initial Eval 6) Enter the body part in the subject field 7) Type in your evaluation or SOAP note. 8) Sign the note only when you are certain that you are finished with it (you will not be able to edit once you sign the note). 9) If you are referring the athlete to a VT Physician, be sure to fill out a yellow Athlete Injury/Illness Referral Sheet and send it with the athlete to the Physician s office. Be sure to record the date at the bottom of the sheet when you make the entry into Injury Zone. B. Existing Injury 1) Select the correct athlete. 2) Select the existing injury and then choose Add Note. 3) Under Injury Notes select ATC Re-eval, Rehab Plan, Assessment, etc. 4) Enter the body part in the subject field 5) Follow the same instructions as above. II. Directions for Physicians A. New or Existing Injury 1) Log into Injury Zone and type in the last name of the patient 2) Select the current injury and review notes about that injury 3) Evaluate the patient 4) Dictate on your digital recorder (using script) or you may select Add note, select Physician initial or reeval for the note type and type in your evaluation of the patient. You may sign your dictation when you are finished. B. New or Existing Illness 1) Under athlete s name select New Illness or select an existing illness. 2) Enter the diagnosed illness with code and enter your name. Save this page or sign the note. 3) Dictate on your digital recorder (using script) or check to proper template on the athlete s

2 Athlete Injury/Illness Referral Sheet and enter any applicable prescriptions and/or comments. 4) Administrative assistant will either get you to sign your dictation immediately or send you a notification on the front page of your Injury Zone account for you to sign. 5) Be sure to enter any scripts given to the athlete in the Prescriptions Section of Injury Zone. *Be sure to use the script for dictating on Injuries/Illnesses Script for Physicians dictating an injury for an athlete that is entered into Injury Zone This dictation is on First Name Last Name_(then spell the last name), and this Injury/Illness can be found under (state diagnosis)in Iinjury Zone. First Name Last Name is here for Initial/re-eval of his/her injury/illness (specify body part or illness). [continue w/ dictation] Dictating on a diagnostic test You may either enter your own note under the Tests section of the athlete s branch by selecting New and then Medical Test, entering the type of test, the injury/illness that the test is being performed for and your name and results of the test or Make sure to begin your dictation on your digital recorder by following the previous script for dictation and then specify that this dictation is on a diagnostic test (specify test). III. Directions for Transcriptionist A. Transcribing on a new or existing injury or illness 1) Log into Injury Zone. 2) Type in the last name of the patient and select the correct patient 3) Select the Medical Summary page from the top. 4) Select the current injury or illness for which the physician is dictating *If there is no injury/illness, add a new one and enter the minimal information. 5) Select Add note 6) Select the proper date for the dictation. 7) Be sure to change the type of note to Physician initial eval or Physician re-eval 8) Change the second drop down box to Anyone can Edit 9) Enter the body part or illness into the subject field 10) Enter the dictation into the main box *Be sure to type the physician s name at the end of the dictation 11) Save the dictation 12) Select the notify button at the top of the screen and notify the dictating physician that they have a dictation ready to sign (to select a physician type their last name and then double click their name) *All dictations by the Fellows should be sent to the Supervising Physician for the day. B. Transcribing on a medical test 1) Type in the last name of the patient and select the correct patient 2) Select New and then Medical test from the athlete branch 3) Enter the type of test, the injury or illness that the test is being performed for and the prescribing physician. 4) Enter the physician s dictation in the results box. *When the Fellows or Dr. Kerger are dictating, be sure to type their name at the end of the dictation. 5) Save the dictation. 6) Select the notify button at the top of the screen and notify the dictating physician that they have a dictation on a medical test ready to sign. *All dictations by the Fellows should be sent to the Supervising Physician for the day.

3 C. Transcribing for Dr. Tilley or Dr. Reynolds 1) Type in the last name of the patient and select the correct patient. 2) Select the Medical Summary Page from the top. 3) Find the Encounters branch and click on the plus sign next to it. 4) Be sure to change the type of encounter to Chiropractic Manipulation 5) Enter Dr. Tilley or Reynolds into the Therapist/Physician drop down box. 6) Enter body part into description box. 7) Enter Chiropractic Manipulation into the Other box. 8) Save the Encounter. 9) To type the dictation, select the encounter again and select Add Note. Follow steps 6-11 from Section III A from here. 10) For Dr. Reynolds, select the notify button at the top of the screen and notify Chad Hyatt that Dr. Reynolds has a dictation ready to sign. Dr. Reynolds will check Chad s account weekly to sign his dictations. *You may sign notes for Dr. Tilley automatically. D. Entering Dictations for Physicals (PPE s) into Injury Zone 1) Type in the last name of the patient and select the correct patient. 2) Select the Athlete Summary from the top. 3) Go to the Notes section at the bottom of the page and select Add Note. 4) Enter the correct date and time of the PPE. 5) Be sure to change the type of note to PPE and Other Yearly Forms 6) Change the second drop down box to Anyone can edit 7) Enter (or that year) PPE into the Subject box. 8) Enter the dictation into the main box. 9) Be sure to type the physician s name at the end of the dictation. 10) Save the dictation and notify the treating physician to sign the note. IV. Directions for Administrative Assistant A. General Patient Flow in the Physicians Office 1) Ensure that all patients that come into the Physicians Office have been evaluated by an ATC and have a yellow Athlete Injury/Illness Referral Sheet (If they do not have a sheet, send them back to the training room to get one!). 2) Log on to Injury Zone and enter the patient s name. 3) Select the Medical Summary page from the top. 4) Look under the Unresolved Injuries or Illness Branch for the matching injury/illness that is listed on the athlete s referral sheet (New Illnesses will not be entered until the athlete has seen the Physician for the first time. New Injuries and Follow-up Injuries and Illnesses should already be in the system. 5) Return the referral sheet to the athlete and instruct them to return the sheet to you at the end of the visit. 6) When the athlete returns the sheet, check to see if there are any templates or comments that the physician needs for you to enter. 7) Be sure to record the date at the bottom of the sheet if it is the first entry into injury zone. 8) Enter the templates and comments as described below and place referral sheet in a file to be returned to the Athletic Training room at the end of the day. B. Entering Injury/Illness Templates 1) Find the existing Illness/Injury and click on it. 2) Select Add Note. 3) Select the proper date for the dictation. 4) Be sure to change the type of note to Physician initial eval or Physician re-eval 5) Change the second drop down box to Anyone can Edit 6) Enter the body part or illness into the Subject field 7) Select the proper template from the Template field. 8) Be sure to change any variables in the template (i.e. medications dispensed, right/left side, etc.) and to add any comments from the athlete s yellow sheet to the end of the dictation template.

4 9) Save the dictation and notify the treating physician to sign the note. V. Directions for Students Entering documents from the To be Scanned box 1) Select the document to be scanned. 2) Scan the document and title it with the last name of the athlete (last name, first initial) and the type of document (i.e. Doe, John- x-ray report) 3) Save the document to the appropriate folder on the desktop of the back computer. 4) Open Injury Zone and attach the scanned document to the appropriate file. 5) Once the document is stored in Injury Zone it may be stamped with the SCANNED Stamp and placed on the desk of the appropriate Staff or GA Athletic Trainer. 6) Each respective Athletic Trainer may deal with the documents in whatever way they choose. Scanned documents may be shredded, however certain documents may be saved for a certain amount of time (i.e. PPE s, surgical pics, etc.). General Guidelines *No direct referrals to a physician will be allowed (except for special circumstances) *All athletes with an injury will be evaluated by a Staff or GA Athletic Trainer and entered into the database before being referred to a physician. They will also be given a yellow Athlete Injury/Illness Referral Sheet to take to the Physician s office. *All athletes with an illness that will be referred to a physician may be referred to a physician without being entered into injury zone, however, it will be the physician s responsibility to enter the diagnosis under New Illness as well as enter any prescriptions given to the athlete.

5 Section Two. Injury Zone Roles/Responsibilities I. Staff/GA Athletic Trainers 1) New Athlete/Staff Information (Demographics, Allergies, Medical Conditions, etc.) 2) Initial Injury Reports (Ensure that injury is in IZ before it sees a physician) 3) Treatments/ATC Encounters 4) Rehabs 5) Referrals 6) Updating Medical and Injury Status Tabs 7) Surgeries (Notes, follow-ups, etc.) 8) Updating resolution of injuries II. Student Athletic Trainer 1) Entering New Athlete Information - Demographics, Sports, Allergies, etc. 2) Scanning storing documents in Injury Zone III. Administrative Assistant IV. Physicians 1) Ensure that athlete has yellow Athlete Injury/Illness Referral Sheet 2) Enter Physician Encounters 3) Enter Diagnostic Testing Results 4) Enter Templates and Comments from Physicans 5) New Athlete/Staff Information 6) Athlete Demographics 1) Signing Dictations (daily) 2) Entering New Illnesses 3) Entering Prescriptions as they are prescribed 4) Fill out appropriate section of yellow Athlete Injury/Illness Referral Sheets

6 Section Three. Injury Zone Cheat Sheet ( What to include where ) I. Athlete Information Page A. Addresses, Phone Numbers, ID Numbers, addresses, etc. of athlete and parents B. Medical Information 1) Height, Weight, Handedness, etc. 2) Medical Alerts (Glasses, contacts, allergies) 3) Medical Categories (Asthmatic, Sickle Cell, Diabetic, Anemic, etc.) 4) Emergency Contact Information in VTSM C. Sport 1) Sport - Select sport from drop down. 2) Rookie Year in League - Enter first day on team D. Notes 1) New(Blue) and Return(Pink) or Exempt(Green) PPE forms and dictations related to that PPE 2) Notes on past injuries and surgeries not incurred/performed at Virginia Tech 3) Signed Virginia Tech Student Health forms (Tuberculosis Assessments, Immunization forms) * Yearly Treatment Standards, Prescription Release/Notification of Medication Usage and NCAA/VT HIPPA Forms will be stored in a yearly notebook. NCAA/VT Drug Testing Consent forms (blue) will be sent to compliance for filing. II. Medical Summary Page A. Illnesses (All ATC and Physician notes pertaining to each illness) B. Injuries (All ATC and Physician notes pertaining to each injury) C. Treatments 1) Daily treatment notes (entered by ATC) 2) Rehab Plans (saved as attachments to a daily treatment note) D. Medical Tests 1) Initial Screening Labs 2) X-rays, MRI s, Bloodwork, CT s, Spirometry, etc. E. Encounters 1) Chiropractic Encounters 2) Pre-game/in office manipulations 3) Game Day Prescription Medication Dispensal 4) OTC Administration 5) Cook Counseling Center Notes 6) Miscellaneous Encounters F. Inoculations 1) Allergy Shots 2) Flu Shots and other Vaccinations G. Prescriptions 1) Any and all prescriptions from Physicians

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