Focus Series 104: Documentation

Risk Management Focus: Documentation
1 CME Category One Credit toward AMA Physicianís Recognition Award

Information

The need for the program was determined from comments from previous seminar participants and from malpractice insurance statistics.

Goals

Physicians make mistakes in the chart; they get very busy and may forget to document certain information. 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. Sometimes these entries are vague or ambiguous, and sometimes they have been made in a deliberate attempt to falsify the records.

Objectives

Know what should be documented in the medical record.
Know how errors in the chart should be corrected.
Understand when and how late entries should be made.
Know what steps should be taken to protect the integrity of the medical record when there are multiple providers.

Methodology

This seminar is a self-study seminar, with CME test.

Target Audience

This seminar is designed for physicians of all specialties who want to sharpen their risk management skills. A basic knowledge of risk management and malpractice is assumed.

Faculty

This seminar was authored by Rosemary Gafner, Ed.D.

CME Information

This seminar is provided in partnership with Medical Risk Management, Inc.

Medical Risk Management, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education to physicians. Medical Risk Management, Inc. designates this continuing medical education activity for a maximum of 1 Category 1 credit(s) toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity.

This activity was planned and produced in accordance with the ACCME Standards for Enduring Materials.

Physicians who satisfactorily complete this seminar with a score of 80 percent or better will receive a certificate of completion that will document their participation in this program.

Required Time

Estimated study time: 45 minutes
Estimated testing time: 15 minutes