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How to screen athletes for mental health risk while protecting confidentiality :

March 19, 2020

PPE: Preparticipation Physical Evaluation, 5th Edition, published by the AAP last year includes revised history, physical examination and medical eligibility forms. As part of an increased focus on identifying and addressing mental health issues in athletes, the history form now includes questions from the Patient Health Questionnaire-4 (PHQ-4) to screen for anxiety and depression (see below).

Many institutions require athletes to submit all three forms rather than just the medical eligibility component. As a result, patients may be hesitant to report sensitive mental health information that could be reviewed by parties outside the medical team. In addition, practitioners may be confused about how to communicate medical eligibility while protecting sensitive health information.

So how can practitioners fulfill their duty to obtain accurate information and report clearance decisions while protecting patient confidentiality?

Purpose of medical eligibility form

The PPE forms are designed to share essential information regarding athlete evaluation, emergency care and future sports participation with those who need to know without jeopardizing protected health information (PHI). PHI is defined as any information that potentially can identify a patient and relates to past, present or future physical and mental health conditions.

The medical eligibility form allows physicians to check one of two boxes to indicate an athlete’s medical eligibility without breaking confidentiality rules governing medical interactions or divulging PHI. The Health Insurance Portability and Accountability Act (HIPAA) allows the release of this medical eligibility information (whether the athlete is “medically eligible for certain sports” or “not medically eligible for any sports”) without the release of other medical information.

The Family Educational Rights and Privacy Act (FERPA), which protects a student’s educational records, also may apply to institutions that receive funding from the U.S. Department of Education.

With or without HIPAA and FERPA regulations, athletes have a right to privacy, and all medical interactions should respect athlete confidentiality.

Use of release forms

When the PPE is performed in an office setting that is not affiliated with the school or sports club, it is safest from a privacy perspective to separate the medical eligibility form from the confidential history and physical portions of the evaluation.

If a school or team requires all three forms, the physician should have the athlete (and parent/guardian if the athlete is a minor) sign a release of medical information form that allows the entire or specific portions of the PPE record with PHI to go to the school or team. Permission to share important medical information with a team physician or certified athletic trainer also must be obtained from the athlete and parent/guardian if the athlete is a minor.

Communicating these policies before and during the PPE may help assure the athlete of efforts to protect confidentiality and increase the likelihood of honest responses to sensitive questions.

All medical records maintained by schools or sports clubs should be kept in secure areas with access limited to authorized medical personnel. Information communicated by electronic means should be encrypted and password-protected. Electronic record systems used to store information obtained during the PPE or other medical encounters should be password-protected and accessed only by authorized medical personnel.

The revised forms in the 5th Edition of the PPE monograph allow increased opportunities to screen for key physical and mental health conditions in athletes. Pediatric providers should feel comfortable using these forms and collaborating with schools and sports clubs to optimize appropriate use to maintain patient confidentiality.

Dr. Koutures is a member of the AAP Council on Sports Medicine and Fitness Executive Committee.


Scoring and interpreting the Patient Health Questionnaire-4

Use of validated questionnaires such as the Patient Health Questionnaire-4 (PHQ-4) can assist in screening athletes for depression and anxiety.

The PHQ-4 asks four questions about elements affecting emotional health. The daily frequency of each set of symptoms is scored on a scale from 0 (not at all) to 4 (nearly every day).

A total score is determined by adding the scores of each of the four items.

Scores are rated as normal (0-2), mild (3-5), moderate (6-8) and severe (9-12).

A total score of 3 or higher for the first two questions suggests anxiety. A total score of 3 or higher for the last two questions suggests depression.

Questions regarding an athlete’s mental health concerns or high-risk behaviors should be addressed when parents/guardians are not present to increase the chance of honest answers. In addition, using a medical eligibility form that is separate from the history and physical examination forms will help protect confidential medical information.

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