A.T. Still University, Mesa, AZ.
California State University, Fullerton.
J Athl Train. 2018 Jun;53(6):619-626. doi: 10.4085/1062-6050-298-17. Epub 2018 Jun 12.
High-quality patient care documentation is an essential component of any health care professional's daily practice. Whereas athletic trainers (ATs) recognize the importance of patient care documentation, several barriers may prevent them from producing high-quality patient care documentation.
To explore beneficial strategies and techniques that ATs perceived would enhance the quality of patient care documentation in the secondary school setting.
Qualitative study.
Individual telephone interviews.
Ten ATs who were members of the Athletic Training Practice-Based Research Network and employed in the secondary school setting were interviewed (4 men, 6 women with 7.1 ± 7.8 years of athletic training experience).
An individual telephone interview was conducted with each participant. Once transcribed, data were analyzed into common themes and categories per the consensual qualitative research tradition. Trustworthiness of the data was achieved through triangulation strategies: (1) the inclusion of multiple researchers to ensure accuracy and representativeness of the data and (2) participant member checking.
Participants identified several documentation strategies they perceived would be helpful to improve the quality of patient care documentation, including mode and consistency of documentation and the need for a standardized process as well as the need for system standardization. In addition, participants discussed the need for more education on patient care documentation. Specifically, they identified ways of learning and strategies for future education to enhance patient care documentation across the profession.
As athletic training continues to evolve, it is crucial that ATs are well educated on how to produce high-quality patient care documentation as a part of routine practice. Continuing professional development opportunities are needed to promote lifelong learning in the area of patient care documentation.
高质量的患者护理文档是任何医疗保健专业人员日常实践的重要组成部分。虽然运动训练师（ATs）认识到患者护理文档的重要性，但有几个障碍可能会阻止他们生成高质量的患者护理文档。
探索 ATs 认为可以提高中学环境下患者护理文档质量的有益策略和技术。
定性研究。
个人电话访谈。
10 名 ATs 接受了采访，他们是运动训练实践为基础的研究网络的成员，在中学环境中工作（4 名男性，6 名女性，平均有 7.1±7.8 年的运动训练经验）。
对每位参与者进行了个人电话访谈。转录后，数据按照共识定性研究传统分析为常见主题和类别。通过三角测量策略实现数据的可信度：（1）纳入多名研究人员，以确保数据的准确性和代表性；（2）参与者成员检查。
参与者确定了他们认为有助于提高患者护理文档质量的几种文档策略，包括文档的模式和一致性，以及对标准化流程和系统标准化的需求。此外，参与者还讨论了对患者护理文档更多教育的需求。具体而言，他们确定了学习方法和未来教育策略，以提高整个专业的患者护理文档质量。
随着运动训练的不断发展，作为常规实践的一部分，对 ATs 进行如何生成高质量患者护理文档的良好教育至关重要。需要继续提供专业发展机会，以促进患者护理文档领域的终身学习。
