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Risk Management Focus
Documentation
Overview
Most physicians can remember reading medical records and seeing entries that are questionable or don’t make sense. On occasion these entries have been made in error (i.e., the event or treatment occurred but was documented in the wrong patient’s chart). Sometimes these entries are vague or ambiguous, and sometimes they have even been made in a deliberate attempt to falsify the record. Good documentation is essential to good patient care, and that’s why this course has been developed.
Objectives
Upon completion of this course, a physician should:
1. Know what should be documented in the medical record.
2. Know how errors in the chart should be corrected.
3. Understand when and how should late entries be made.
4. Know what steps should be taken to protect the integrity of the medical record when there are multiple providers.
Target Audience
This course is appropriate for all physicians.
Methodology
This is a self-study course consisting of text and CME test. Physicians should read the course content, answer the test questions and submit the answers for scoring. Those who complete the course with a score of 80 percent or higher will earn a maximum of 1 AMA PRA Category 1 creditTM.
Faculty/Author
This course was developed by Rosemary Gafner, Ed.D. Dr. Gafner’s CV is available on request or online at https://www.medrisk.com/Medrisk/Faculty/CV/default.aspx.
CME Information
Medical Risk Management, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. Medical Risk Management, Inc.designates this continuing medical education activity for a maximum of 1 AMA PRA Category 1 creditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is valid for release May 1, 2007 and expires on April 30, 2010.
Commercial Support
This activity was developed solely by Medical Risk Management, Inc. without any outside commercial support.
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