NEW: Injury Consult - Step-by-Step Instructional User-Guide

SEPARATED CONSULT (TREATMENT) NOTES AND INJURY DIAGNOSIS

This improved workflow offers several key advantages for clinicians:

• Enhanced Information Sharing – Consultation and treatment notes are now entered in a stand-alone form, allowing for greater flexibility in selectively sharing relevant information with other disciplines.
• Improved Security and Privacy – Injury diagnosis details are recorded separately, ensuring stricter control over sensitive medical information.
• Linking one consult to multiple injuries – Clinicians now have the ability to associate multiple injury diagnoses with a single consultation note.
• Seamless Integration – Through built-in form linking, clinicians can easily enter or associate new consultation records with existing diagnosis records directly within the Consult form.

DOCTORS and PHYSIOS (INJURY) CONSULT

CENTRALISED DATA ENTRY METHOD

Clinicians will now use the "Doctors and Physios (Injury) Consults" form as the primary entry point for documenting:

• Injury treatment records
• New injury diagnoses
• Linking other data relevant to an injury

Key Improvements

Unlike the previous "Injury Record" form, clinicians now complete a new consultation form for each session with an athlete. This updated workflow allows clinicians to link not only the relevant injury diagnosis but also additional data—such as ForceDecks assessments—within a single, comprehensive record. This approach enhances clinical documentation and provides a more complete and detailed view of the athlete's condition and progress.

Accessing the Form

The form is readily available as a quick-link under "Favorite Events" on the landing page. To access it:

• Hover over the tile, select "Enter Data," and locate the relevant athlete.

DOCTORS and PHYSIOS (INJURY) CONSULT

Consultation notes continue to use the SOAP style format within the "Doctors and Physios (Injury) Consults" form.

• Subjective

  • Clinical history

  Objective

  • Objective or physical examination

  Impressions

  • Diagnosis (including differential diagnoses) and general impressions, such as factors contributing to the diagnosis

  Treatment

  • Treatment that the patient received during this consultation, for example soft tissue work, rehab or interventions (e.g. injection)

  Plan

  • Management plan for the athlete

VIEWING SHARED CONSULT DATA FROM OTHER DISCIPLINES

Each discipline will have its own version of the new Consult Form.

All practitioners across disciplines will have the ability to selectively share relevant information with other disciplines.

This section enables clinicians to review data entered BY their discipline and those shared WITH their discipline while conducting their consultation, ensuring better collaboration and continuity of care.

To access a more detailed history of medical consultations and shared communications, medical leadership recommends opening a second tab with the front page dashboard. This setup enables you to explore and review the athlete’s historical records while efficiently switching between tabs to enter notes during the current session.

INJURY DIAGNOSIS

To improve workflow efficiency, enhance data security, and provide greater control over information sharing, the Doctors and Physios (Injury) Consults form and the Injury Diagnosis form have been separated into two distinct forms.

Linking a Consultation to an Injury Diagnosis

When it's time to associate a consultation with an injury diagnosis, clinicians have two options within the consult form:

1. Create a new Injury Diagnosis directly from the consult form, or
2. Link to an existing Injury Diagnosis already recorded for the athlete.

To support clinical decision-making, the Show Injury Diagnosis History feature allows clinicians to easily view the athlete’s previous injury records.

CREATING A NEW INJURY DIAGNOSIS RECORD

When an athlete presents for an assessment of a new injury, a new injury diagnosis needs to be created. Within the "Doctors and Physios (Injury) Consults" form:

Locate the section titled “DOES THIS CONSULT HAVE AN INJURY DIAGNOSIS?”

• Start a New Record – Click the "+ New" button to open the Injury Diagnosis form.
• Make a New Diagnosis - It is important that the most precise diagnosis be selected. 

This step can be completed (or adjusted) at any stage in the process of completing the Injury Diagnosis. 

Many clinicians choose to make (or adjust) their diagnosis once a thorough history and physical examination have taken place. 

Diagnostic code update

On 23 April 2024 the Orchard Sports Injury and Illness Classification System (OSIICS-15) was published as the successive iteration of the OSICS-14.

The new Injury Diagnosis record now uses OSICS 15 codes, meaning diagnoses are selected from a database field instead of a body chart.

NOTE

• Historical injury records with older OSICS codes have been re-coded using guidelines from discipline leads and uploaded into the new form for consistency.
• Original injury records will still be available for review if needed.

DATE OF INJURY OCCURRENCE

The initial field requests the date that the injury occurred. This is distinct from the date of the first clinical assessment, which might often occur days after the injury occurred.

The date of injury may be obvious in the event of an acute injury but will require the clinician's/athlete's discretion if the injury was insidious in nature.

INJURY CLASSIFICATION

This field determines if the injury is a new type of injury (new diagnosis) or a recurrent injury (same diagnosis as a previous injury). 

A recurrent injury should only be selected if the injuries have exactly the same diagnosis and are on the same side (left/right) as the previous injury. 

An exacerbation of an injury is also considered a recurrent injury.

INJURY ONSET

The injury onset relates to the manner of which the injury commenced. 

Acute: an injury following an instantaneous transfer of energy to the body (e.g. hamstring strain with immediate commencement of pain and/or dysfunction)

Repetitive – Sudden Onset: an injury caused by an accumulated energy transfer that occurs with an identifiable single event (e.g. a tibial stress fracture sustained from a gymnastic dismount, that occurred with a pre-existing bone stress reaction)

Repetitive – Gradual Onset: an injury caused by an accumulated energy transfer without an identifiable single event (e.g. a gradual increase in Achilles pain over a month, diagnosed as Achilles tendinopathy)

Other: This option may be selected for cases that do not relate to acute or repetitive onsets (e.g. symptoms related to ankylosing spondylitis).

Additional information is frequently required to accurately capture the circumstances surrounding an injury. As such, certain fields—specifically Activity at Time of Injury and Mechanism of Injury—have been conditionally hidden and will only appear when relevant options are selected.

To support consistent data collection across sports and programs—and to enhance the ability to compare data meaningfully—the available field options have been reviewed and standardized by discipline leads and relevant working groups. This refinement ensures that all users are selecting from a common, network-wide set of options tailored to each sport, enabling more reliable analysis and benchmarking across the system.

If an athlete does not have appropriate options available in the form, they should be directed to complete a new AMS Account Details form. This will ensure their sport and discipline information is up to date and that the relevant data fields are properly populated.

ADDITIONAL INJURY DETAILS

These fields are designed to gather detailed context about the injury, including:

• The surface on which the injury occurred (e.g., grass, snow, surf etc.),
• Environmental conditions at the time of injury,
• The equipment involved at the time of injury,
• Equipment related injuries.

Depending on the options selected, other fields will become visible for data collection to accurately capture the circumstances surrounding an injury

INJURIES REQUIRING SURGERY

Any surgery performed for injury management should also be recorded within the injury diagnosis form.

This section collects the date that the surgery was performed under Surgery date and allows for free-text related to the surgery to be entered under Surgery details.

The date of surgery should be captured. This allows the pre-operative window (and injury burden) to be separated from the post-operative burden.

Multiple surgeries can be entered per injury by clicking the +Add 

COMPLETING THE INJURY DIAGNOSIS FORM

Once the Injury Status section has been completed, select Save and Close. This action will return the clinician to the currently open Doctors and Physios (Injury) Consults form.

 

MULTIPLE DIAGNOSES LINKED TO THE SAME CONSULT

When an athlete sustains more than one injury—whether at the same anatomical site or across different body sites—each injury must be documented in a separate Injury Diagnosis form.

Example:
If an athlete sustains both an MCL injury and a concussion during the same incident, two individual Injury Diagnosis forms must be completed—one for each injury.

Within the NEW workflow:

1. The clinician begins by creating a new Consultation form entry.
2. The first Injury Diagnosis (e.g., MCL injury) is created and completed.
3. After saving and closing that entry, a second Injury Diagnosis (e.g., concussion) is created and also linked to the same Consultation form.

Additionally, if a new injury occurs while the athlete is still undergoing treatment for a previous injury:

• Use the "Link" function to connect the existing injury, and the "New" function to add the new injury.

LINK TO AN EXISTING INJURY DIAGNOSIS

When conducting a follow-up consultation for an athlete—i.e., not the initial visit for the current injury—the following steps should be taken:

1. Open a new Doctors and Physios (Injury) Consult form.
2. Enter your notes in the Consult Notes section.

Scroll down and select “Link” to connect the current consult entry to the relevant injury diagnosis record(s) that it pertains to.

This process allows the clinician to document the review appropriately while referencing and maintaining continuity with previous injury records.

UPDATING INJURY STATUS

After linking an injury diagnosis to the consultation form, clinicians are required to confirm that the STATUS of all relevant injuries has been updated appropriately.

This can be done via the “Quick edit” function within the Doctors and Physios (Injury) Consult form:

• Clicking on the pencil icon, clinicians can select “+Add New Status” and select the new relevant option.
• Once selected and the “Save” button clicked, this new status will be assigned to the Injury Diagnosis.

DISCONTINUATION OF MAINTENANCE Rx AND HANDOVERS FORM IN AMS

The Maintenance Rx and Handovers form will no longer be used within the AMS.

Clinicians should instead open a Doctors and Physios (Injury) Consults form. Rather than creating a new injury diagnosis or linking to an existing one, they should select the appropriate field indicating that no diagnosis or medical condition is associated with the consultation.

This applies to scenarios such as:

• Performance-focused treatments provided in the absence of injury (e.g., manual therapy to improve hip flexion for better rowing mechanics),
• Documentation related to injury prevention programs,
• Discussions with athletes, coaches, or performance staff aimed at optimising health and performance

LINKING OTHER DATA SOURCES TO THIS CONSULT

This section of the new Consult Form workflow allows clinicians to access other forms or view stored data without leaving their consultation form.

In collaboration with discipline leads and working groups, each new consult form will include a selection of key and commonly used data entry forms. This enables clinicians to:

1. Show Historical Information – View past entries from other relevant forms.
2. Create a New Record – Enter data within a separate data form by navigating from within this form. Click "+ New" to open a data entry form, complete it, and click "Save" to return to the current consult form. 
   • Example: A Physician in the Medical discipline can seamlessly add a new allergy entry during their consultation.
3. Link Information – Clicking "Link" allows you to attach relevant data from another form to this consultation. This helps create a more complete record and gives practitioners additional information to share with others when needed.

FOLLOW UP FLAGS

This section enables clinicians to flag follow-up dates and required actions, which will appear in the ACTIONS section on the landing page.

SHARED COMMS

The Shared Comms section allows clinicians to control what information is shared and who it is shared with.

This section is designed to facilitate communication with other disciplines across the DPE AND the National program (where relevant) by sharing relevant athlete information important to the care of the athlete, while protecting confidential or unrelated details from being disclosed.

Once athlete consent has been obtained, clinicians can customise shared content by selecting from the following options:

1. Specific injury details
2. Individual consult note fields
3. Additional shared notes, and
4. Add summary data from linked forms.

This ensures clear, purposeful communication that respects athlete privacy.

IMPORTANT: Specific Injury Details

Selected fields will be sent to a chosen practitioner's dashboard.

However, if these details are to be included within the shared comms summary (see next slide), then the last field in this slide “would you like to add the linked record information from above?” needs to be selected YES.

Once a clinician has:

• Discussed information sharing with the athlete and obtained their consent, and
• Selected the specific information to be shared with other practitioners,

they can then choose who to share the consult summary with.

In this example, the clinician has chosen to share information only with practitioners holding Strength & Conditioning, Performance Support Manager, or Coach roles within the AMS—provided those users also have access to the athlete.

The clinician can then click “Save and Lock” to save the record and initiate sharing with only the selected recipients.

Clinicians will have 72 hours to make further edits before the record is permanently locked.

CLOSING AN INJURY

According to the Data Dictionary, an injury record should be closed when "the injury has recovered from a medical perspective and no longer requires active clinical intervention."

Maintaining accurate and up-to-date injury records is essential. A key part of this is ensuring all injury records are closed once the athlete‘s injury has resolved OR the athlete no longer requires care.

How to Close an Injury Record

Injury records can only be closed via the Injury Diagnosis form. To do so:

1. Clinicians should open a new Doctors and Physios (Injury) Consults form.
2. Navigate to the athlete’s Injury Diagnosis record by clicking on the relevant injury.
3. Scroll to the bottom of the form and update the athlete’s Injury Status to either Full training and Competition (if not already done).
4. This will enable the option to “Close” the record.
5. Select “Save and Lock” to finalise and permanently lock the entry.

Additional Notes

It is recognised that clinicians—particularly those not embedded within sporting environments—may find it challenging to keep injury records current, especially when athletes miss review appointments (often due to having recovered).

However, it remains the clinician’s responsibility to maintain accurate records for the relevant National Sporting Organisation (NSO) or National Institute Network (NIN) provider. This ensures that reliable injury data is available to the appropriate governing body.