HIPAA, FERPA, and SOAP Notes in Athletic Training

HIPAA

Health Insurance Portability and Accountability Act.

HIPAA

Regulates how ATs, PTs, OTs, physicians, administrators and other allied health personnel can share private health information of patients with other people.

HIPAA

For patients, guaranteed access to their medical records and more control over how their protected health information is used and disclosed.

HIPAA

Provides clear direction if medical privacy is compromised.

HIPAA Authorization

Patient must authorize to release medical information, including core elements such as description of how info will be used or disclosed, identity of authorized person(s), purpose of use or disclosure, identity of person(s) whom the entity is authorized to provide or disclose health info, expiration date or event, individual signature and date, and description of authority if using personal representative.

FERPA

Family Educational Rights and Privacy Act.

FERPA

Protects privacy of student's educational records and gives parents rights with respect to their child's educational records.

FERPA

Rights transfer to the student once they reach 18 or attend school beyond secondary level.

FERPA

Parents and eligible students have the right to inspect and review the student's educational records and request a school correct records that are inaccurate or misleading.

FERPA

Schools must have written permission to release student's records from the parent or eligible student.

HIPAA and FERPA

In some instances, medical records are kept along with a student's educational records; the right to privacy of medical records is protected under FERPA, not HIPAA in this instance.

Scenarios

HIPAA or FERPA?

SOAP

Acronym for 4 major sections in patient note: Subjective, Objective, Assessment, Plan.

Subjective

Clinician states info received from patient (or caretaker) that's relevant to their present condition, necessary to plan the tests and measures that will be in examination, and necessary to justify goals that will be set.

Demographic information

Information given from patient regarding current conditions/chief concerns, onset date, contributing factors/incidents, self-care for condition, things making condition better or worse, if they are seeing anyone else for condition, and level of pain.

Limitations and restrictions

Information given from patient regarding current conditions/chief concerns, prior and current level of function, ADLs, goals for treatment/rehabilitation/therapy, cultural and religious beliefs, social history, employment status, physical environment and available resources.

General health status

Information given from patient regarding current conditions/chief concerns, social habits, growth and development, family health history, medications, past history, and anything they deem relevant.

Objective

Results of tests, results of measurements taken, and objective observations from clinician.

Common mistakes in Objective section

Not stating affected body part, not stating measurable information, and not stating type of whatever is being measured.

Assessment

Evaluation section that is mandatory and supports the need for intervention, including components like impairments of structure and function, activity/participation restrictions, personal factors, environmental factors, future tests and measures, and patient progress.

Diagnostic statement

Relationship between patient's activities/participation restrictions and patient's impairments and medical diagnosis, which is different than the diagnostic statement made by a physician or equivalent counterpart.

Prognosis

Predicting level of improvement in activities/participation and total amount of time needed to reach that level.

Plan

Plan for patient interventions, including type, planned progressions, forms of treatment patient will receive to achieve anticipated goals, frequency of visits, anticipated length of time for course of rehab/therapy, plans for further examination, and referral information.