Implementation of Medical Documentation Sign-in Sheets for Patient Evaluations and Treatments: A Quality Improvement Project

Authors

• Madicyn Barnes, University of South CarolinaFollow
• Beth Davis, University of South CarolinaFollow
• Kaitlyn L. Holland, University of South CarolinaFollow
• Zachary K. Winkelmann, University of South CarolinaFollow

Keywords

secondary school, patient care, PDSA

Abstract

Context: Medical documentation of athletic training services at a large, public secondary school was limited to clinically significant or legally sensitive information entered into the electronic medical record (EMR) system. There are only 2 full-time athletic trainers (ATs) providing medical services to over 800 student-athletes across 45 different teams throughout the school year. Due to the large patient load, documentation is difficult to complete and, therefore, limited to the most “significant” information. The purpose of this quality improvement project was to improve medical documentation at this secondary school by implementing physical sign-in sheets in the athletic training facility (ATF) to better monitor patient encounters.

Methods: All athletic training staff, including professional athletic training students, certified athletic trainers, undergraduate observation students, and high school student aides, were trained on the system's goals to ensure proper flow and implementation. Student-athletes took a notecard upon entering the ATF and noted their first and last name, date, sport, body part and side to be evaluated, and type of treatment to be completed. Upon leaving the ATF, patients dropped their cards off for the AT staff to enter into the EMR later.

Results: Results suggest that implementing a physical sign-in system increased the number of patient encounters properly entered into the EMR. The new system was effective, with some days showing a 100% - 240% increase in documented patient encounters. Over the course of the intervention cycles, patient adherence improved as the student-athletes became more familiar with the new system. As a result, more cases were recorded and the strain on the athletic training staff decreased.

Conclusions: Keeping track of medical documentation throughout the day, rather than recalling all encounters at the end of the workday, eased the burden on the athletic trainers. A simple sign-in system with proper training for student-athletes and athletic training staff improved documentation and allowed the athletic training staff to better manage their time.

Recommended Citation

Barnes, Madicyn; Davis, Beth; Holland, Kaitlyn L.; and Winkelmann, Zachary K. (2026) "Implementation of Medical Documentation Sign-in Sheets for Patient Evaluations and Treatments: A Quality Improvement Project," Clinical Practice in Athletic Training: Vol. 9: Iss. 2, Article 3.
DOI: 10.51221/sc.cli.2026.9.2.3
Available at: https://scholarcommons.sc.edu/clinat/vol9/iss2/3