The EMR is comprised of a documentation system as well as an Injury Surveillance Component (ISC). Within each of these two components are several primary pieces that create the complete system.
The EMR has the ability to register new patients, record personal demographic information (e.g., PCP, guardian, and contact information), initial injury demographics, complete injury evaluation, daily treatment notes, progress notes, and discharge evaluations and summaries.
The system is organized by patient names, with the ability to quickly search through registered patients in your clinic using the AT Dashboard as well as access patient injuries and files from a centralized Injury Menu. In essence, the EMR acts like a virtual filing cabinet for secure storage of patient records.
The ISC is designed to integrate seamlessly with the EMR system, and to eliminate the need for double data entry. All that is required of the athletic trainer is to record the number of participants for each team’s practices and games throughout the week. All incidences of injury, time loss, severity, etc. are automatically calculated via the documentation system within the EMR system.
One of the unique features of the EMR is the built-in patient-oriented outcomes instruments. For each injury that is recorded into the system, a series of general and region-specific outcomes instruments are available for the patient to complete. These instruments provide valuable information to the athletic trainer regarding how the patient is progressing with his or her injury, and the overall effectiveness of the care being provided.
The patient can complete outcomes instruments in the athletic training room at the time of evaluation, or log onto the system from home.
Integration of patient-oriented outcomes will help to improve clinical practice, not only with individual patients, but also within the profession as a whole, as we work to characterize athletic training practice through the work of the AT-PBRN clinicians and researchers.
Each component of the EMR is explained in detail within this manual. It is our hope that you will be able to utilize this system to effectively improve your patient documentation and overall care with a more efficient, intuitive, and effective documentation and injury surveillance component, in addition to contributing valuable information to the efforts of the AT-PBRN.