Medical Conditions Course 1 Part 1 PDF

Foundational Issues OBJECTIVES At the completion of this chapter the reader should be able to do the following: • Discuss the basic differences between orthopedic and medical assessment. • Appreciate the athletic trainer as a health care provider in the recognition, referral, and disposition of...

Foundational Issues OBJECTIVES At the completion of this chapter the reader should be able to do the following: • Discuss the basic differences between orthopedic and medical assessment. • Appreciate the athletic trainer as a health care provider in the recognition, referral, and disposition of medical conditions. • Practice effective communication in the medical assessment of the physically active person. • Apply principles of disease transmission prevention. • Implement the regulations and laws that govern the care and privacy of patients. • Compare CPT and ICD codes to medical conditions. • Recognize the importance of patient-reported outcomes (PROs) and evidence-based practice (EBP) in the comprehensive evaluation and treatment of a patient’s medical condition. • Explain the purpose of the preparticipation examination (PPE) for athletes, and identify the medical organizations that provide guidelines. • Differentiate the office visit from the stationbased PPE. 1 This introductory chapter provides an overview of the foundational premises for subsequent chapters in the following broad categories: communication, prevention of disease transmission and legal considerations, medical care, and disposition. It touches on many topics briefly such as medical coding, evidence-based practice, and patient-reported outcomes. Although not covered in depth here, these topics can apply to every chapter, so a quick review of their relevance is important. Chapter 1 also reviews the role of the athletic trainer in the diagnosis and treatment of medical conditions, the importance of effective communication, the prevention of disease transmission, legal concerns, and the administrative aspects of the preparticipation examination (PPE). Role of the Athletic Trainer in Evaluation of Medical Conditions Although this text is not exclusively for certified athletic trainers (ATs), they are often the first to detect an athlete’s potential medical issue. A brief description of the education and training of ATs is useful here so that readers can understand their role. Athletes who are feeling ill commonly turn to the athletic trainer because the AT is the most accessible health care provider. Athletic trainers establish a rapport with their athletes and are familiar with their medical histories and their normal performance, as well as the demands the sport places on their bodies. This may enable the AT to detect a condition that otherwise might go unnoticed. The AT working with college or professional teams is also responsible for the health care of the entire team while traveling with the team to games and events. Although many athletic issues are orthopedic in nature, the conditions an athletic trainer encounters can also include infections, colds, and other maladies K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. 3 4 Medical Conditions in the Athlete Certified Athletic Trainers An athletic trainer is a health care professional who provides services under the direction of or in collaboration with a physician. To enter the profession, candidates must graduate with a degree in athletic training from a Commission on Accreditation of Athletic Training Education (CAATE) accredited athletic training education program. The fall of 2022 will be the last time an undergraduate can enroll in a CAATE-accredited AT program to seek a bachelor’s degree in AT and sit for the national Board of Certification (BOC) exam to practice athletic training. After this time, all professional AT programs will be delivered at the master’s degree level only. ATs work with physicians in a number of settings, most traditionally in high school, college, professional, and Olympic sports. They can also be found in clinics, hospitals, and industry. All athletic training students must have a minimum of two years of clinical experience within college credit courses that must be completed with different populations and various levels of risk, including nonorthopedic or medical conditions. The proposed 2019 CAATE standards include additional skills in both emergent and nonemergent medical situations. • ATs must pass a national certification examination (from the Board of Certification) after college graduation. • Most states also require state licensure or registration to practice athletic training in that state. Commission on Accreditation of Athletic Training Education 2015. that need to be identified quickly and treated properly in order for the athlete to perform at optimal levels. It has been nearly 20 yr since the National Athletic Trainers’ Association (NATA) first identified a new series of educational competencies and clinical proficiencies in several areas that were not previously part of an athletic trainer’s preparation: pathology of injury and illness, pharmacology, and general medical conditions and disabilities (Commission on Accreditation of Athletic Training Education 2015). These competencies and proficiencies have since then been included in athletic training curricula throughout the United States and have been expanded in subsequent professional requirements. The athletic trainer continues to assume a greater role in health care of patients, and this places more emphasis on the clinical diagnosis and the coordinated plan of care for patients’ medical problems. In part, this is a result of advances in medical science that now enable athletes with medical conditions to compete at the highest levels. It also is the result of expanding employment opportunities for ATs. Athletic trainers are employed in industries, inpatient hospitals, outpatient clinics, and other nontraditional workplaces as well as in the traditional realms of interscholastic, intercollegiate, and professional sport. Athletic trainers work carefully with physicians and see a more diverse population, including pediatric athletes, physically active mature and older adults, and those with physical impairments. Because ATs are health care providers who work with diverse populations, they must be effective communicators. They must be able explain to the pediatric patient her medical condition in terms she would understand and also be able to relay lab and diagnostic reports to other professionals in the medical community. Athletic trainers can defend their decision to the coach to deny participation to an asthmatic athlete, and they can provide explicit take-home care instructions to the parent of a concussed athlete. All of these transferals of medical knowledge require an ability to accurately relay facts and to respect the intended audience. Communication in the Medical Field Effective communication is one of the most critical aspects of evaluating a patient. Communication takes many forms, from the initial encounter with the patient to determining the chief complaint, acquiring critical information, and sharing the findings with the patient and with other health care providers if warranted. Communication With Patients Because the medical examination is centered on symptoms, the nature of the initial meeting and the questions asked when acquiring a health or illness history are as critical as the information gained from them. The patient must be comfortable enough to openly discuss his or her symptoms. Effective communication depends on the practitioner’s familiarity with the patient, respect for cultural, gender, language, or other potential barriers, and an ability to maintain a pleasant and interested demeanor. One way to promote dialogue between the practitioner and the athlete is to ask open-ended questions, such as “Why have you come to see me today?” Being empathetic—for example, “That sounds difficult.”—and allowing pauses that give the athlete time K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. Foundational Issues CLINICAL TIPS Effective Communication With Patients • Ask open-ended questions. • Maintain eye contact, if culturally respectful. • Display an open, relaxed posture. • Repeat key words spoken by the patient. • Use simple phrases for encouragement, such as “go on” or “mm-hmmm.” for additional comments can reassure the patient that the clinician is listening carefully. Asking how the patient feels about the symptoms is also appropriate in medical assessment. A good practitioner can summarize and interpret the athlete’s comments by saying, “I hear you say…” rather than by empathetically injecting words or opinions into the conversation during the subjective review of symptoms. Along with verbal communication skills, the health care provider must be sensitive to cultural, ethnic, and gender issues. In certain cultures, touching is impermissible because it violates a personal space. In others, direct eye contact is disrespectful. Knowing the patients or asking them if they are comfortable is a good beginning. A person will more freely give a medical history if the health care provider uses a quiet and private place to communicate. The health care provider must always be aware of the surroundings when communicating with an athlete about a medical issue. When a practitioner assesses a patient of a different gender, a person of the athlete’s gender should be present in the room as well. Using proper draping and maintaining privacy during physical examinations or discussion of private topics are critical. Communication With Health Professionals Federal regulations allow health care providers to exchange information about a patient’s medical care. This exchange can occur after the patient grants permission under the Health Insurance Portability and Accountability Act (HIPAA). Athletic trainers should be familiar with medical terminology so that they can discuss medical conditions with other health care providers. Because some communications among health care providers take the form of written notes or electronic records (Electronic Medical Record—EMR), athletic trainers must understand typical medical terminology and standard medical abbreviations. The “Common Medical Terminology” sidebar lists common medical conditions and situations that are used throughout this text. Medical Referral People working with injured or ill patients know that a delay in receiving medical attention may result in lasting damage or possible death. Because many team physicians specialize in orthopedic or family practice, ATs should have access to other medical doctors (MDs) or doctors Common Medical Terminology adventitious—Coming from an external source; occurring spontaneously afebrile—Without a fever; also apyretic biopsy—Removal and examination of tissue comorbid—Two or more possibly unrelated medical conditions existing at the same time constitutional—Relating to the body as a whole erythema—Redness of the skin brought about by capillary dilation febrile—Having a fever malaise—A general feeling of discomfort or uneasiness; often the first symptom of an illness or infection morbidity—Consequences of a given illness mortality—Death from a particular illness or disease palliative or supportive—Reducing the severity of an illness or treatment of disease without curing it prodromal—Preillness symptoms purulent—Pus filled sequela, sequelae—A condition occurring as a consequence of a given illness or disease suppurative—Pus forming K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. 5 6 Medical Conditions in the Athlete Sending an athlete with a concussion to an orthopedic surgeon may not be the most effective (or affordable) referral if the physician does not have training in concussion management. Before making a referral, determine what the physician can contribute to the athlete’s well-being and safe return to activity. CLINICAL TIPS Knowing the Difference Between a Sign and a Symptom Although generally mentioned together during the assessment of a medical condition, signs and symptoms are not synonymous. • Sign refers to something that the athletic trainer sees or feels, such as a temperature, respiration, heartbeat, or blood pressure. A sign can be objectively measured or assessed. • Symptom (Sx) refers to something the athlete feels or tells the AT, such as a headache, nausea, dizziness, or pain. Federal Regulations Pertaining to Communication Among Medical Professionals The right of the athlete to have personal medical information protected against dissemination to outside parties is of the utmost importance. These outside agents may include the media, coaches, or even parents if the athlete is over age 18 and can function as an adult. Although it is common to cite an orthopedic reason for an athlete’s inability to participate, many athletes do not explicitly give permission to reveal medical conditions that prevent their full activity. Even when they sign a form that allows medical information to be shared with parties such as coaches, insurance secretaries, professional scouts, and the media, this form typically applies only to injuries of osteopathy (DOs) for the referral of specific medical conditions in their athlete-patients. ATs should know the differences among the various medical specialties (see table 1.1) in order to direct athletes to the right providers. TABLE 1.1 Health Care Providers Degree Title BS/BA MS/MA PhD/ doctorate Postgraduate Prescribing education authority AT Athletic trainer X X X DC Doctor of chiropractic X +4 yr DO Doctor of osteopathy X +7 yr X DPM Doctor of podiatry X +4 yr X EMT Emergency medical technician (initial 6 wk course) EMT-P Paramedic (various levels, including intubation or IV administration) LPN Licensed practical nurse (1 yr technical degree) MD Medical doctor X +7 yr X NP Nurse practitioner X X OT Occupational therapist X X X PA Physician’s assistant (intensive 26 mo program) X X X PhD Psychologist X X X PT Physical therapist X X X PTA Physical therapy assistant (associate’s degree) RD Registered dietitian X X RN Registered nurse X X X X X IV = intravenous. K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. Foundational Issues that are orthopedic in nature; it does not cover medical issues such as sexually transmitted infections (STIs) or other diseases. Students in the health care fields must be aware of the regulations for their field. The NATA Code of Ethics and the Board of Certification that oversees the Standards of Professional Practice for certified ATs, for example, both include principles for the preservation of privileged information and requirements for adherence to federal laws (National Athletic Trainers’ Association 2013; Board of Certification 2016). Case law has routinely protected the athlete from violations of patient privacy, citing discrimination and Americans with Disabilities Act protections in cases of athletes with HIV or AIDS (Wong and Apostolopoulou 1999). Disclosure of medical information without a patient’s express permission is illegal and falls under two federal acts that govern personal health information (PHI), depending on the age of the athlete: HIPAA and the Family Educational Rights and Privacy Act (FERPA). HIPAA HIPAA, also known as Public Law 104-191, was implemented in 2003. It is the first federally mandated act to protect patient privacy, oversee medical records, and give patients more control over how and to whom their personal health information is disclosed (United States Department of Health & Human Services 2016). Specifically, the law allows patients to see their medical records and request corrections if factual errors are discovered. It places limits on the use and sharing of PHI outside of health care agencies—for example, with a life insurance company. The act dictates how PHI may be disseminated in given situations, verbally or electronically. The U.S. Department of Health and Human Services Office for Civil Rights provides oversight and enforcement of HIPAA (United States Department of Health & Human Services 2016). FERPA FERPA, also known as the Buckley Amendment, was created in 1974 to protect the privacy of student education records, and it applies to any school receiving funds from the U.S. Department of Education (United States Department of Education 2016). It functions similarly to HIPAA in that it gives people access to and limits disclosure of their educational records. Parents have a right to inspect a child’s educational records until the student is 18 years old. After the student becomes a legal adult and attends a school beyond high school, the rights transfer from the parent to the student. After this, parents have no right to their adult children’s educational or medical records unless the children sign a waiver (United States Department of Education 2016). The act allows only certain parties access to educational records without prior permission in given situations. An example is “appropriate officials in cases of health and safety emergencies” (United States Department of Education 2016). An educational record may contain biographical information, grade point averages, records of student conduct, and test scores. Disclosing without prior consent that a particular athlete weighs a certain amount, is an orphan, took remedial reading classes, or plagiarized is a violation of this act. The consequences of disclosure range from loss of certain federal funds to prosecution of a criminal offense. Medical Records Adequate records on the health care of athletes must be kept, and everyone who has access to these records must appreciate and abide by confidentiality and the athletes’ right to privacy as well as preserving HIPAA and FERPA confidentiality (National Collegiate Athletic Association 2014). These records must be maintained and stored in areas with limited access in accordance with institutional and state regulatory acts, and they must be safeguarded against improper disclosure at all times. Limited access applies to the monitoring of daily injury reports, the athletes’ status, the results of diagnostic tests, and the accessibility of medical files. Even daily treatment logs, e-mails with identifiable information, and fax transmissions must be considered privileged information. Unsecured files, open storage areas, or unprotected computers without password encryption are examples of inappropriate medical record storage. Abbreviations used among health care workers are considered appropriate and legal methods of keeping notations on medical records. The athletic trainer and other health care providers must be familiar with these abbreviations because they save time and space when writing notes into charts. Electronic Medical Records Many companies provide electronic services to update and maintain medical records. Typically, an institution subscribes with a vendor for services to update, repair, and maintain the software and server. The only restrictions are the amount of money the institution has for this type of service and the size of the server it wishes to maintain. Many electronic medical records (EMRs) permit electronic exchange between providers and insurance carriers on secure sites. This allows medical providers at different venues to gain access to provider notes, X-ray and lab results, diagnostic tests, and other information. Some EMRs also provide for communication with patients about appointments, lab and diagnostic results, and any follow-up needs. Often the institution can have the software tailored to meet its specific needs. K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. 7 8 Medical Conditions in the Athlete Prevention of Disease Transmission Everyone who works in health care appreciates the need to prevent disease transmission. Protection from infection and maintaining a sanitary environment are two critical elements in caring for patients with illnesses. Another prevention technique is immunization from specific diseases by vaccine. Chapter 15 discusses vaccination as well as established standards for preventing the spread of disease and illnesses. There are federal mandates that address the prevention and spread of disease. States and institutions may also impose restrictions for safety on their subjects, and health care providers must know the policies and regulations for their own workplaces. Intercollegiate sports medicine guidelines require that all necessary materials, such as barriers, bleach, waste receptacles, and wound coverings, comply with universal precautions and be available to all health care providers (Parsons 2014). The Occupational Safety and Health Administration (OSHA) sets standards to protect health care workers and their patients. OSHA standards apply only to established relationships between employers and employees and do not extend federal protections to students (United States Department of Labor 2016b). However, students such as those in the health care, who could be exposed to hazardous waste in facilities where they practice or observe, should follow the safety standards set forth by OSHA, receive training, and have ready access to precautionary materials, such as barriers and proper disposal containers. OSHA can inspect any facility under its auspices without prior notification, and it has the power to suspend or shut down a facility as well as to impose hefty fines for noncompliance with standards (United States Department of Labor 2016b, d). The most familiar OSHA requirement affecting athletic medical care concerns the bloodborne pathogens (BBP) standard. Athletic trainers must be intimately familiar with this standard because athletes often receive open wounds in the course of their activities, with the consequent risk of infection. Bloodborne Pathogens The OSHA bloodborne pathogens (BBP) standard is intended to safeguard health care workers against hazards resulting from exposure to infectious body fluids, and it covers anyone who could reasonably anticipate having occupational exposure to infectious waste (e.g., blood). Included in this standard is a description of how to formulate an individualized institutional or setting exposure control plan. A written document outlines steps to take and specific people to call in the event of an exposure to infectious waste. An exposure may range from a needle stick to blood spilled onto intact skin. All health care workers must have an operating knowledge of their employer’s plan, access to personal protective equipment, BBP training, and knowledge about whom to contact should an exposure occur (United States Department of Labor 2016d). Typically, these instructions are visibly posted throughout the facility. The BBP standard uses the phrase universal precautions to emphasize that all human waste should be treated as if it were infectious and that health care workers and patients must be protected in every situation in which they might be exposed to body fluid, including contact with mucous membranes in the eyes, mouth, or nose; genital secretions; or blood. Any sharp object that may be contaminated with infectious waste, such as needles, scalpels, or broken glass, is also considered potentially hazardous material (United States Department of Labor 2016d). CLINICAL TIPS Handling Infectious Waste • All infectious waste must be placed in a closeable, leakproof-approved container for storage, transporting, or shipping. • An OSHA-approved plan for proper disposal of infectious waste bags and sharps units must be on hand and followed. • Gloves must be worn when personnel handle infectious laundry. • Laundry contaminated with infectious waste must be separated from other materials to be cleaned. • Personal protective equipment (gowns, masks, gloves) shall be properly disposed of before leaving the treatment room or on contamination. • While wearing gloves, personnel may clean bloodstains on material (uniforms, towels) with hydrogen peroxide in cold water and immediately rinse. • Only red hazardous waste bags should be used to dispose of infectious materials. • In the absence of antibacterial soap and running water, personnel should use antibacterial wipes or gels to sanitize hands often. • Personnel should avoid putting ungloved hands to face (eyes, nose, mouth) when around ill patients or when working with infectious waste. Data from Parsons 2014; United States Department of Labor 2016a-d. K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. Foundational Issues The National Collegiate Athletic Association (NCAA) and National Federation of State High School Associations (NFHS) have explicit regulations that address infection control and bleeding athletes or those with blood on their uniforms (Parsons 2014; Beaschler 2015; National Federation of State High School Associations 2015). These regulations require that a bleeding athlete be removed from activity until the bleeding has been stopped and the wound covered with a dressing sturdy enough to withstand the demands of activity. Soiled uniforms must be cleaned or changed before resumption of activity (Parsons 2014). Again, the requirements of storing and disposing of infectious waste are intended to protect both the athlete and the health care provider and prevent them from transmitting diseases. All health care workers must have ready access to barriers that fit properly in order to retard infection from hazardous materials. Washing with soap and water is the best way to clean hands before and after glove use. If soap and water are not readily available, commercial disinfectant gels or single-use wipes can sanitize hands. Workers should remove and properly dispose of soiled barriers before leaving the treatment area. Brightly labeled red infectious waste bags are the most common means of storing such waste until it can be disposed of per OSHA protocol. These bags must be contained in a sturdy, leakproof container with a lid and located in an easily accessible area for all to use. Barriers to Disease Transmission Sharps containers are specifically built, self-contained units that have one-way valves (figure 1.1) and are used to accommodate sharp instruments such as needles and scalpels that may have infectious materials on them. Some sharps containers are locked to a wall so that only an OSHA-approved provider can remove them for proper disposal. These containers should never be opened or overstuffed. Typically, institutions that have sharps containers have a service that maintains them, including scheduled emptying and inspection for safety. Barriers are devices worn to protect both the health care worker and the patient against the spread of disease. The traditionally accepted barrier is latex gloves, but OSHA also requires access to face and eye protection, gowns, and mouthpieces for resuscitation (Parsons 2014; United States Department of Labor 2016d). Health care workers with allergies to latex must be provided with an alternative material suitable as a barrier against the transmission of BBPs. CLINICAL TIPS Correct Glove Use 1. Thoroughly wash all aspects of both hands and fingers, with liberal use of an antibacterial soap and plenty of water. 2. Dry hands with a disposable single-use hand towel. 3. Apply gloves without touching the external surfaces of the gloves. When the procedure requiring gloves is complete: 1. Use the gloved index finger and thumb of one hand; gently pinch the glove at the wrist and pull toward fingertips. 2. Invert the glove, and remove all but index finger and thumb. 3. Repeat the procedure with the second hand, inverting the glove as it is removed. 4. Fold gloves inside out and dispose of them in a red (OSHA-approved) bag. 5. Thoroughly wash and dry hands as described previously. Sharps Containers Disinfection Another component of prevention in the spread of infections is disinfection of surfaces used for examination, and treatment and disinfection of soiled materials, including uniforms and clothing. Disinfection is a critical aspect of every athletic training facility because of its potential to stop the spread of disease. The simple acts of sterilizing FIGURE 1.1 A sharps container. K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. 9 10 Medical Conditions in the Athlete treatment tables after use and washing hands often can diminish disease transmission considerably. Many infections, such as hepatitis B, are quite hardy and can live outside the body if not obliterated properly (see chapter 15). The Environmental Protection Agency (EPA) registers all disinfectants in the United States. The EPA has prior approval on all test methods companies use to determine whether their product is effective against a particular organism (United States Environmental Protection Agency 2016). Disinfectants approved by the EPA have a registration number on the label of the product as well as a list of organisms targeted. To be labeled as “hospital strength” a disinfectant must eradicate 100% of all organisms listed on the label. Household chlorine bleach contains 5.25% active sodium hypochlorite and 94.75% water. Although it is extremely effective against Staphylococcus and Streptococcus bacteria, Salmonella, Escherichia coli, certain fungi, and influenza A and B, it is not a cleaner. The EPA and U.S. Department of Agriculture have deemed chlorine bleach safe for use in food preparation and as a disinfectant. It is registered with the EPA for appropriate use as a hospital disinfectant, and the Centers for Disease Control and Prevention have written guidelines for its use in health care facilities (United States Environmental Protection Agency 2016). The difference between a disinfectant and a disinfectantcleaner is that a disinfectant merely kills microorganisms, whereas a combination cleaner removes soils and disinfects in one step. Regulations governing how these cleaners and disinfectants are dispersed include the following: If the material is removed from its original container, it must have all the product information transferred to the second receptacle, including a notation that the cleaner was moved, for example, from a gallon container to a spray bottle (United States Department of Labor 2016a). When sanitizing surfaces soiled with possible BBPs, OSHA recommends properly using barriers, cleaning all blood from the surface and properly disposing of the waste, and then disinfecting the area (United States Department of Labor 2016c). CLINICAL TIPS OSHA Mandates on Disinfectant Agents • Contaminated surfaces must be sprayed to saturation with the disinfectant. • HIV-1 disinfection requires 30 s of saturation. • Hepatitis B virus disinfection requires 10 min of saturation. From United States Department of Labor 2016c. The 2014–2015 NCAA Sports Medicine Handbook suggests using a 1:100 ratio of freshly prepared bleachto-water solution for disinfecting surfaces (Parsons 2014). Calling for a more proactive approach to disinfecting surfaces, the NFHS recommends cleaning equipment and pads weekly with this bleach solution (National Federation of State High School Associations 2015). Legal Considerations, Medical Care, and Disposition This section offers a brief overview of several topics relating to medical care. It begins with a short discussion on the legal aspects of providing quality medical care and continues with patient disposition. Patient-reported outcomes (PROs) and evidence-based practice (EBP) are two important components of delivering appropriate care to patients. Entire textbooks have been written on both of these areas, so we only touch upon them here. Next, the classification systems that assist with coding diagnoses and prescribing treatment are discussed. The purpose of this short section is to help you to see the importance of the coding and how it assists with tracking trends and insurance payments. Finally, we discuss the importance and administration of the preparticipation exam for athletes. Legal Considerations As with everything else, legal ramifications must be considered when caring for athletes. Health care providers hired to evaluate athletes and prevent illnesses and injuries have a duty to their employers, and subsequently their patients, to render appropriate medical care. The word duty here is a legal term, one of the four components considered in proving negligence. Breaching a duty, and therefore causing harm, is negligence. Athletic trainers also have other duties to their athlete-patients. Among them are maintaining skills and knowledge, providing a reasonable standard of care, giving medical referrals if necessary, and upholding patients’ right to privacy. Negligence is conduct that falls below an established and expected standard of care validated by law for the protection of others, which results in physical or mental harm or damage to another. Typically, case law helps us to interpret what the standard of care should be in a given situation. In the case of Kleinknecht v. Gettysburg College, the court held that the college had a duty to protect against medical crisis, specifically to adopt a policy that might avoid life-threatening emergencies (1992). In another case, the presence of a qualified medical person at certain practices but not others was not deemed in itself to be a violation of the standard of care owed an athlete K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. Foundational Issues (Kennedy v. Syracuse University 1995). In this situation, the athletic trainer was always present at higher risk sports events. A serious wrist injury occurred at a different venue but was not caused or worsened by the failure of the athletic trainer to habitually attend football practice but not gymnastics. Other recent lawsuits claim death occurred because of failure to recognize athletes suffering from a sickle cell crisis (Price 2005; Fainaru-Wada 2008), permanent disability from returning to play with a concussion (Hetzner 2009), and death resulting from clearing an athlete to play with a concussion (Letchworth 2009). The privilege of being a certified and state-licensed or registered AT does carry with it certain obligations. Athletic trainers are held to a higher standard than are physical education teachers or personal trainers because of their training, experience, and national certification. Among the critical obligations is establishing and practicing a venue-specific emergency action plan (EAP) to address catastrophic events that may occur within the realm of athletic participation. Components within the EAP include access to early cardiac defibrillation, the presence of or access to a physician, communication between on-site personnel and a medical facility, and transportation to a medical facility (Parsons 2014). The NCAA Sports Medicine Handbook is updated annually and specifically discusses the role of the health care provider in many medical aspects of sport, including issues related to bloodborne pathogens, concussions, sickle cell trait, pregnancy, and other conditions. The BOC Standards of Professional Practice has several references to the expected level of care its members should give to patients (Board of Certification 2016). Athletic trainers would be wise to review their job descriptions to clearly delineate their roles and responsibilities and to understand the expected standard of care. Because most ATs do not see as many medical conditions as they do orthopedic problems, they must also work within established guidelines, such as under the direction of a team physician, especially when working with medical disorders. It is critical to know when a medical condition is beyond the athletic trainer’s scope of practice and should be referred. Patient-Reported Outcomes Patient-reported outcomes (PROs) are generally used in the clinical setting when data are collected directly from patients. Their purpose is to engage patients as active partners in their own progress and to determine if a given treatment is working. PROs are often presented as scales (Likert 1–5) or numerical sets (1–10) that correlate with how the patient is feeling. Typical sections of a PRO include symptoms, disability (how well the patient is or is not functioning daily), health status, quality of life (QoL), and general health concerns or perceptions. Each type of health issue can have its own questionnaire. For example, a PRO for a patient with heart valve replacement will be different from one who has chronic psoriasis. Clinical trials use PROs to determine if a given treatment or therapy was effective from the patient’s point of view, and often a clinic will tailor a PRO to meet the needs of the patient or condition. There is a lot of research on validating PROs for given conditions. One of the more common valid PROs is the Short-Form 36 (SF-36) that offers 36 short questions pertaining to the patient’s health. PROs are critical to the application of evidence-based practice. Evidence-Based Practice Evidence-based practice (EBP) entails blending the best research evidence and clinical expertise to make health care decisions. EBP involves the patients’ values and preferences to create a complete research–practice–patient circle. This type of practice begins with a patient-centered problem or concern, followed by the creation of a very specific question or desired outcome. The health care provider must then seek appropriate, validated research or resources to assist with research. The health care provider must have a strong grasp of how robust the research is, how valid the instrument or assessment is, and how sensitive or specific the treatment is in working toward the desired outcome. EBP is engaging and promotes curiosity. It involves using best practices for a given condition. Clinicians should encourage patients not only to participate, but also to engage in their own treatment. Classification and Surveillance Systems There are two national medical classification systems: one that categorize diseases and conditions (International Classification of Diseases) and another that tracks treatments, procedures, and therapies (Current Procedural Terminology). It is important to be familiar with these classification systems because they are widely used both to track disease trends and types and to follow developments in treatments and therapies. People working in medical offices, hospitals, and clinics will also use the systems to code insurance billing as well as determine trends in treatments. International Classification of Diseases In 1983, the United States government mandated a medical classification system that linked diagnosis-related groups for the purpose of cataloging and medical recordkeeping. Since then, people responsible for billing and reimbursement have used the International Classification of Diseases (ICD) manual, which is currently in its 10th revision (ICD-10). K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics. 11 12 Medical Conditions in the Athlete The World Health Organization (WHO, Geneva, Switzerland) established the ICD to provide statistical data on the morbidity and mortality of medical conditions. Since 1988, physicians seeking reimbursement for services rendered have been required to submit diagnosis codes for any Medicare patient. The seven-digit codes are organized in the following manner: There are 22 chapters of codes (chapters I– XXII) that assign specific alphabetic codes and numbers (A00–B99 is in chapter 1; Z00–Z99 is in chapter XXII) to certain tissues, injuries, or causes of death (table 1.2). Chapter I is Certain Infectious and Parasitic Diseases, whereas chapters IX and XV are Diseases of the Circulatory System, and Pregnancy, Childbirth, and Puerperium, respectively. Following the alphabetic letter are the twodigit main codes. Typically, a dot provides separation between the main code and any qualifier. A qualifier can be three to seven digits, alphabetic, numeric, or a combination of both. The qualifier can indicate many things, including etiology, anatomical site, and severity. The ICD is primarily used to diagnose and track conditions, but it helps insurance companies to determine when to cover a given procedure for a given ICD code. For example, a patient with a third sinus infection in a relatively short period may be allowed a CT of the sinuses to determine if there is another underlying condition (Centers for Medicare and Medicaid Services 2015). Current Procedural Terminology Unlike the ICD, Current Procedural Terminology (CPT) provides a set of billing codes, descriptions, and TABLE 1.2 Chapter guidelines associated with procedures and services used by health care professionals. This manual is published annually in January by the American Medical Association (AMA), and it contains five-digit codes that identify the procedure or service rendered. The CPT is divided into six sections and each has subsections. Like the ICD, there are often numbers following the code with a decimal point to further identify a given service. The use of the plus (+) symbol indicates that procedures were performed in combination (e.g., 97005 is “athletic training evaluation” and could be combined with 97033 “iontophoresis” and 97140 “manual therapy techniques”). Preparticipation Examination The purpose of a preparticipation examination (PPE) is not only to determine readiness for a specific sport but to identify any potential or correctable conditions that may impair the athlete’s ability to fully perform. In general, the PPE is the first interaction a health care provider has with an athlete. This examination is not a true physical but a screening procedure that sheds light on potential problems associated with activity. The American Academy of Family Physicians (AAFP) recommends that all athletes have a PPE for the primary purpose of identifying any medical problems or conditions that could affect participation in sports (American Academy of Family Physicians et al. 2010). Without this examination, an athlete with systemic illnesses or a family history of cardiovascular disease may not be discovered or treated appropriately. The AAFP, along with other medical Sample of the Alphanumeric Coding for ICD-10 Code numbers Description I A00–B99 Certain infectious and parasitic diseases II C00–D49 Neoplasms IV E00–E89 Endocrine, nutritional, and metabolic diseases V F01–F99 Mental, behavioral, and neurodevelopmental disorders VI G00–G99 Diseases of the nervous system VII H00–H59 Diseases of the eye and adnexa VIII H60–H95 Diseases of the ear and mastoid process IX I00–I99 Diseases of the circulatory system X J00–J99 Diseases of the respiratory system XI K00–K95 Diseases of the digestive system XII L00–L99 Diseases of the skin and subcutaneous tissue XIV N00–N99 Diseases of the genitourinary system XV O00–O0A Pregnancy, childbirth, and puerperium XIX S00–T88 Injury, poisoning, and certain other consequences of external causes XX V00–Y99 External causes of morbidity and mortality K. Walsh Flanagan and M. Cuppett, Medical Conditions in the Athlete, 3rd ed. (Champaign, IL: Human Kinetics, 2017). For use only in Medical Conditions Course 1–Sport Medics.