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When considering medical record keeping within the athletic training room, the clinician should be aware of various best practice guidelines. For example, in terms of paper-form medical records, it is best practice to store these records in a locked cabinet that is not easily accessible to the general public. As with all methods of medical record keeping, there are specific guidelines to consider when using a web-based, electronic medical record (EMR) system. In the following pages, best practice guidelines related to EMR use are identified and described. It is recommended that the athletic trainer review and follow these guidelines and incorporate any additional standards set forth by his/her school, school district, and/or state that is related to the use of an EMR system within his/her athletic training room.
Family Educational Rights and Privacy Act (FERPA) release form – All information entered into the EMR is uploaded and transmitted to secure, redundant servers in real-time and never stored on local computers. While this process provides added security to the storage of the entered information, the transmission of this information is regulated under FERPA. Just as the athletic trainer would be required to have the patient/parent/legal guardian to sign a FERPA release form to transmit information (eg, fax, email) to a team/family physician, it is recommended that the athletic trainer obtain formal approval from the patient/parent/legal guardian prior to registering the patient into the EMR system. To facilitate this process, we have included a generic FERPA release form that the athletic trainer may use for his/her practice. To expedite this process, it is recommended that the athletic trainer include a similar form in pre-participation examination packets.
Computer access and security – While the EMR is designed to provide a high-level of security, it is recommended that the athletic trainer take additional steps to limit computer access to non-healthcare professionals and ensure the privacy of all medical records and information. It is recommended that the athletic trainer change his/her computer settings so that the computer hibernates/sleeps/switches to a screensaver within a minute of idling and then require a password in order to re-access the computer. This will limit the ability for a person, other than the athletic trainer, to access the computer and view personal health information that has been entered into the system.
End of year/ Archiving patients
End of year/ Archiving patients
Regularly archiving patietns who are no longer at your workplace can allow it to function better.
To archive patients navigate to the home page (Athletic Trainer Dashboard) and click the dropdown next to the view button and select archive patient. You will be prompted to confirm your selection and the name will appeared greyed out until you refresh the page or until your next login.
Un-archiving patients
Un-archiving patients
If you mistakenly archive a patient you can scroll to the bottom of the Athletic Trainer Dashboard and see all patients. After selecting the AT dashboard will re-load and you can search for the patient you would like to un-archive and click the dropdown next to the view button for their profile and select "Unarchive Patient"
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