The Preparticipation Physical Evaluation.

The preparticipation physical evaluation (PPE) is a common reason for young athletes to see a primary care physician. An annual PPE is required by most state high school athletic associations for participation in school-based sports, although there is limited evidence to support its effectiveness for detecting conditions that predispose athletes to injury or illness. In 2019, the American Academy of Pediatrics, with representatives from the American Academy of Family Physicians and other organizations, published updated PPE recommendations (PPE5). According to the guideline, the general goals of the PPE are determining general physical and psychological health; evaluating for life-threatening or disabling conditions, including risk of sudden cardiac arrest and other conditions that may predispose the athlete to illness or injury; and serving as an entry point into the health care system for those without a medical home or primary care physician. The guideline recommends that the evaluation take place in the physician's office rather than in a group setting. The PPE should include a structured physical examination that focuses on the cardiovascular, musculoskeletal, and neurologic systems. Screening for depression, anxiety disorders, and attention-deficit/hyperactivity disorder is also recommended. Clinicians should recognize any findings suggestive of the relative energy deficiency in sport syndrome. Additional consideration is required to address the needs and concerns of transgender athletes and athletes with physical and intellectual disabilities. Finally, guidelines have been published regarding return to play for athletes who have had COVID-19.

Documentation proficiency of patients who leave the emergency department against medical advice.

STUDY OBJECTIVE: This study describes the current documentation practices of health-care providers in the emergency department (ED) during the discharge against medical advice (AMA) process. METHODS: This retrospective cohort study reviewed health care provider documentation of adult patients who left an ED AMA in one year. Each encounter documentation was reviewed for eight medicolegal standards including the documentation of 1) the patient's capacity; 2) the signs and symptoms; 3) the extent and limitation of the evaluation; 4) the current treatment plan, risks, and benefits; 5) the risks and benefits of forgoing treatment; 6) the alternatives to suggested treatment; 7) the explicit statement made by the patient who left AMA, as well as the explicit documentation of what the patient was refusing; and 8) the follow-up care including discharge instructions. RESULTS: There were 81,038 eligible ED encounters with a total of 418 patients identified as having left AMA resulting in an AMA discharge rate of 0.52%. No single chart fulfilled all eight medicolegal standards. Minimal standards established by the Emergency Medical Treatment and Active Labor Act (EMTALA) were fulfilled in only 17 charts (4.1%). Despite general acceptance in the legal and policy literature on the need to ensure capacity to make decisions, only 22.0% of the charts documented that the patient had such capacity. CONCLUSIONS: This study revealed suboptimal documentation in AMA cases by clinicians at a single ED and confirms disparities between federal and academic quality (safety documentation requirements and actual provider documentation).