Good and Bad Medical Record Documentation: From Claims Management to Optimal Patient Care Outcomes
Inadequate or inaccurate medical record documentation increases the risk of medical errors and legal liability. Accurate and timely medical record documentation facilitates diagnosis and treatment, communicates pertinent information to other caregivers to ensure patient safety, and supports optimal care delivery and patient outcomes. Learn more about documentation best practices with Dr. Mark Hauser.
NOTE: This course is mandatory for advanced practice providers new to the Baptist Health Medical Staff. This course is required at initial appointment only.
Samaritan Physicians: Successful completion of this activity will qualify Samaritan physicians for annual policy discounts. Upon completion, please print your certificate and submit to Samaritan for consideration.
Original Release Date: December 2017
Review Date: September 2023
Medical Staff Physicians, Advanced Practice Providers, Clinical Employees, Pharmacists, Respiratory Therapists and Occupational Therapists.
- Execute accurate documentation of medical necessity in patient medical records.
- Describe the impact medical necessity documentation has on the perception of hospitals, payer and public databases for patient acuity.
- Reduce the risk of legal liability associated with improper or incomplete maintenance of patient medical record documentation.
- Assess system deficiencies to improve medical record documentation, delivery of care and patient outcomes.
- Evaluate the impact of improper documentation on claims management.
Mark J. Hauser, M.D., FACP, FCCP
President, Medical Staff Affairs
Baptist Hospital of Miami
Mark J. Hauser, M.D., FACP, FCCP, faculty of this educational activity, has no relevant financial relationships with ineligible companies* to disclose and has indicated that the presentation or discussion will not include off-label or unapproved product usage.
J. Arturo Fridman, M.D., conference director of this educational activity, has no relevant financial relationship to disclose with ineligible companies.*
Non-faculty contributors and others involved in the planning, development, and editing/review of the content have no relevant financial relationships to disclose with ineligible companies*.
*Ineligible companies -- Companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Baptist Health South Florida is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Baptist Health has been re-surveyed by the ACCME and awarded Commendation for 6 years as a provider of CME for physicians.
Baptist Health South Florida designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 1.00 AMA PRA Category 1 Credit™
- 1.00 General certificate of attendance
- 1.00 Nurse Practitioners
- 1.00 Florida Board of Occupational Therapy
- 1.00 Florida Board of Pharmacy
- 1.00 Florida Board of Respiratory Therapy
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