9109: Documentation - Information That Serves as Your Record

Course Description

This course outlines and discusses the essential and basic principles of documentation to guide providers in creating a more accurate, objective, timely, and complete medical record. Utilizing actual claim examples to illustrate documentation issues that presented challenges to the defensibility of a lawsuit, providers will identify documentation fundamentals to create a more relevant and defensible medical record, while increasing patient safety and outcomes.

Learning Objectives
  1. Utilize documentation fundamentals to create a more accurate, objective, timely, and complete medical record that aid in increasing patient safety and decreasing the likelihood of litigation
  2. Identify risks associated with untimely documentation, use of an EHR system, and alterations to the medical record
  3. Recognize areas of documentation that pose potential risks to patient safety and incorporate current documentation recommendations in the practice of medicine

Credit Awarded

  • 5% Premium Credit for Physician Policyholders
  • 1.0 CME Credit for Physicians
  • Certificate of Participation for Non-Physicians

 

 

 

Course summary
Course opens: 
01/01/2024
Course expires: 
12/31/2026

Faculty & Authors

This course was developed by SVMIC’s Risk Education and Evaluation Department: Shelly Weatherly, JD, VP; Julie Loomis, RN, JD, AVP, Risk Education; Trish Campbell, BSN, LNCC, Director of Risk Education; and Jeff Woods, JD, Risk and Practice Management Senior Attorney.


CME Information

Accreditation:  This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Tennessee College of Medicine (UTCOM) and State Volunteer Mutual Insurance Company. 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 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AAFP:  The AAFP has reviewed Documentation: Information That Serves as Your Record and deemed it acceptable for up to 1.00 Enduring Materials, Self-Study AAFP Prescribed credit. Term of Approval is from 01/01/2024 to 12/31/2024. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AOA:  This program is eligible for one (1) credit hour in Category 2 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, or AOA members may self-report the activity.

Continuing Education for Non-Physicians:  The UTCOM will issue Certificates of Participation to non-physicians for participating in this activity and designates it for CEUs using the national standard that 1 hour of educational instruction is awarded .1 CEU.

This activity was reviewed by Michael McAdoo, MD, on April 17, 2023. This activity was released on January 1, 2024 and will expire on December 31, 2026. SVMIC will not process any completions after December 31, 2026.

             


CME Disclosures

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.

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