Wiki Appropriate for medical record??

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I work for an orthopedic clinic. The clinic is contracted to provide athletic Training Services for our local high school. Our athletic trainer will go to the high school and monitor practices and help students with training issues as needed stretching icing rehab that sort of thing. She wants to document her visits with these kids in the medical record. I do not think that sort of thing belongs in our EMR. I do not feel that this is an appropriate thing to put in the clinic medical record. These training visit she has with them are something through the school they are not actual medical health care at our Clinic. What is everyone's thoughts on this am I correct or not does anyone have any documentation supporting why or why this should not be in the chart? I personally do not think it's something that should be in there but I need to prove my stance on this. Thank you
 
Why do you feel this should be excluded from the medical record? If the trainer is an employee of the clinic and providing these services on behalf of the clinic, I would think that it would be important to maintain a complete and accurate record of everything that was done. If there were ever an injury or a allegation of liability, it would be important to have accurate records on file. If you were to separate these from the rest of your patient records and maintain two different sets of records, I would think doing that would be not only less efficient but also potentially more problematic. I'm not aware of any regulation or other reason prohibiting this information from being included in the EMR.
 
I feel it should be excluded because the athletes being seen are being seen as part of a school program. They are not actual patients of the clinic, there has been no HIPAA info signed off. Other than those reasons, I don't have a concrete reason, I just have a gut feeling, which is why I am seeking further info.
 
Well, in a certain sense, they are patients of your clinic if your clinic is receiving compensation for the trainer's services and your trainer is under your clinic's employment and supervision, and presumably also covered by the clinic's liability insurance. As for HIPAA, that law mainly governs privacy and security and how information is shared with other entities - I don't know that it addresses internal use of an EMR. However, that fact that your clinic is not including the students in their clinic's HIPAA practices brings up additional questions.

All this said, it sounds like you are seeking legal advice here about the operation of a business and a medical practice - because these issues can become complex and getting to the right answer can require more information about your individual situation, I would really recommend that this be discussed with your clinic's attorney or legal firm. There could be other factors involved here such as local or state regulations governing the trainer's practice and the record-keeping requirements. The coding forum is useful for general discussion but isn't be the best place to get definitive advice on the specific steps a practice needs to take to protect itself and remain compliant.
 
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Thank you for your help. I am going to push admin to allow me to speak to legal on this. You are right, it's not a simple answer.
 
When I worked for a cardiology office as a medical assistant, we did cardiac testing on student athletes from the local university. Most, if not all, were not established patients of the clinic. I'm not sure contractually what had been worked out or what papers the front desk had them sign, but a chart was created for them and their test results were put in. I agree with the above, that if anything were to happen it would be best to have the information in the chart. I do recall some students having to come back for more testing and even seeing the physician. I don't think the physician would have been happy if the tests results weren't documented for their review, especially considering there were likely no other records in the chart for these students.
 
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