9115: Documentation - Information That Serves as Your Record
This course is also offered as an eBook self-study. Policyholders who have already completed the eBook version, course #9109, are not eligible to complete this online course for premium credit. Premium credit will not be given for completing the same course twice. If you are unsure whether you have already completed the eBook, click here to submit an inquiry.
This course is an ONLINE self-study. You will be required to complete this course and take the test online. If you would rather have PDF materials emailed directly to you, you will need to register for the eBook version here: 9109: Documentation - Information That Serves as Your Record.
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.
- 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
- Identify risks associated with untimely documentation, use of an EHR system, and alterations to the medical record
- Recognize areas of documentation that pose potential risks to patient safety and incorporate current documentation recommendations in the practice of medicine
This course is a digital reading option. It consists of pages of text, followed by a test.
- 5% Premium Credit for Physician Policyholders
- 1.0 CME Credit for Physicians
- Certificate of Participation for Non-Physicians
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.
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.
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.
- 1.00 AMA CME
- 1.00 Attendance
DISCLAIMER: This course is also offered as an eBook self-study. Policyholders who have already completed the eBook version, course #9109, are not eligible to complete this online course for premium credit. Premium credit will not be given for completing the same course twice. If you are unsure whether you have already completed the eBook, click here to submit an inquiry.