Organizational Expectations Regarding Documentation Practices in Athletic Training

Abstract

Context Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training leaving individual organizations responsible for setting expectations and enforcing policies. Previous research has examined clinician documentation behaviors; however, the supervisor's role in creating policy and procedures, communication expectations, and ensuring accountability has not been investigated. Objective Investigate supervisor practices regarding support, hinderance, and enforcement of medical documentation standards at an individual organization level. Design Mixed-methods. Setting Online surveys and follow-up interviews. Participants We criterion sampled supervising athletic trainers (ATs) (n=1107) in National Collegiate Athletics Association member schools. The survey collected responses from 64 participants (age=43±11 y, years of experience as supervisor=12±10 y) (access rate = 9.6%, completion rate = 66.7%) and 12 (age 35±6 y, years of experience as supervisor=8±5 y) participated in a follow-up interview. Data Collection and Analysis We used measures of central tendency to summarize survey data and the consensual qualitative research approach with a 3-person data analysis team and multi-phase process to create a consensus codebook. We established trustworthiness using multiple-analyst triangulation, member checking, internal and external auditing. Results Less than half of supervisors reported having formal written organization-level documentation policies (n=45/93, 48%), procedures (n=32/93, 34%), and an expected timeline for completing documentation (n=24/84, 2%). Participants described a framework relative to orienting new and existing employees, communication policies and procedures, strategies for holding employees accountable, and identifying purpose. Limitations included lack of time, prioritization of other roles and responsibilities, and assumptions of prior training and record quality. Conclusion Despite a lack of clear policies, procedures, expectations, prioritization, and accountability strategies, supervisors still felt confident in their employees' ability to clear complete and accurate records. This highlights a gap between supervisor and employee perceptions as practicing ATs have reported uncertainty regarding documentation practices in previous studies. Although supervisors perceive high confidence in their employees, clear organization standards, employer prioritization and mechanisms for accountability surrounding documentation will result in improved patient care delivery, system outcomes, and legal compliance.