Explanation should include

• documentation is a written record of observations and actions related to a certain medical event
• documentation facilitates communication among healthcare professionals and other significant parties
• guidelines exist regarding documentation in medical-related professions
• the ethical and legal considerations of record-keeping.

Process/Skill Questions:

• What are the legal requirements of record-keeping, including record format, retention, and accessibility, in professions associated with sports medicine?
• What ethical issues relate to record-keeping and documentation in professions associated with sports medicine?
• What is a subjective, objective, assessment, and plan (SOAP) note? When should SOAP notes be written by certified and/or licensed allied healthcare professionals?