9049: Risk Reduction Series - Documentation
This course outlines and discusses the basic principles of documentation for both paper and electronic medical records which will help providers create a more concise, objective and descriptive record.
Utilizing case examples to illustrate documentation issues which presented challenges to the defensibility of a lawsuit, you will learn documentation strategies to create a more accurate, relevant and defensible medical record.
Target Audience: This course is designed for physicians and other clinicians who want practical information on reducing risk in documentation, particularly in the medical practice setting.
- Better describe patient presentations by documenting in concise, objective terms.
- Utilize documentation strategies to create a more accurate, relevant and defensible medical record.
- Identify risks and benefits of electronic medical documentation, including the use of templates, cloned notes, copy & paste and auto-population.
- List the top 3 documentation issues that have been identified through medical record audits.
- 10% Premium Credit for Physician Policyholders
- 2.0 CME Credits for Physicians
- Certificate of Completion for Non-Physicians
Faculty & Authors
This course was developed by SVMIC’s Risk Education and Evaluation Department: Shelly Weatherly, JD, VP; Judy Vinson, RN, CPHQ, LNCC, AVP, Risk Evaluation Services; Julie Loomis, RN, JD, AVP, Risk Education. Reviewed by Michael A McAdoo, MD, on September 21, 2018.
Accreditation: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the University of Tennessee College of Medicine (UTCOM) and SVMIC. The UTCOM is accredited by the ACCME to provide continuing medical education for physicians.
AMA Credit Designation: The UTCOM designates this enduring material for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AAFP: This Enduring Material activity, Risk Reduction Series: Documentation, has been reviewed and is acceptable for up to 2.00 Prescribed credit(s) by the American Academy of Family Physicians. AAFP certification begins 01/01/2019. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA: This program is eligible for two (2) credit hours in Category 2-B of the Continuing Medical Education Program of the American Osteopathic Association. Physicians will need to submit a letter of completion from the University of Tennessee directly to the AOA to receive CME credits.
ANCC: This continuing nursing education activity is pending approval from the Tennessee Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
Continuing Education for Non-Physicians: The UTCOM will issue Certificates of Completion to non-physicians for completing this activity and designates it for a maximum of .2 CEUs using the national standard that 1 hour of educational instruction is awarded .1 CEU.
This activity was released on January 1, 2019 and will expire on December 31, 2020. SVMIC will not process any completions after December 31, 2020.
No commercial support was received for this activity. No speakers plan to discuss off-label use. No planners or speakers have relevant financial relationships to disclose.
This course is intended to be a general overview course for practitioners on the most common documentation topics.