Documentation Practices of Athletic Trainers Employed in the Clinic, Physician Practice, and Emerging Clinical Settings.

CONTEXT: The documentation practices of athletic trainers (ATs) employed in the secondary school setting, including their strategies for, barriers to, and perceptions of documentation, have been characterized in previous research. The documentation practices of ATs employed in other settings have yet to be studied in depth.
OBJECTIVE: To examine the documentation practices of ATs employed in the clinic, physician practice, and emerging clinical settings.
DESIGN: Qualitative study.
SETTING: Web-based interviews. PATIENTS OR OTHER PARTICIPANTS: A total of 22 ATs 11 employed in the clinic or physician practice setting and 11 employed in an emerging clinical setting. DATA COLLECTION AND ANALYSIS: The ATs employed in the settings of interest were recruited with purposeful, convenience, and snowball sampling. Participants were interviewed using a Web-based platform so that we could learn about their behaviors and perceptions of documentation. Data were analyzed using the consensual qualitative research approach, followed by a thematic analysis. Trustworthiness was addressed using data source triangulation, multiple-analyst triangulation, and an established interview guide and codebook.
RESULTS: Participants described following clear guidelines for documentation established by regulatory agencies, employers, and electronic medical record templates. They were motivated to document for patient safety and to demonstrate value. Participants typically documented in real time and continuously, which was facilitated by employer requirements. The ATs described experiencing a learning curve for documentation due to the unique requirements of their settings, but learning was facilitated by employer guidance and mentorship.
CONCLUSIONS: Employer guidelines, training, and ongoing support facilitated effective and thorough documentation in these clinical settings. Athletic trainers and employers in a variety of settings should consider establishing clear guidelines to promote thorough and effective documentation. © by the National Athletic Trainers' Association, Inc.