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

Target Audience

Medical Staff Physicians, Advanced Practice Providers, Clinical Employees, Pharmacists, Respiratory Therapists and Occupational Therapists.

Learning Objectives

  • 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.
Additional information
Bibliography: 
  • Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians Clinical Documentation in the 21st Century. Annals of internal medicine, 162(4), 301-303.
  • Soto, C. M., Kleinman, K. P., & Simon, S. R. (2002). Quality and correlates of medical record documentation in the ambulatory care setting. BMC health services research, 2(1), 22.
  • Garcia, A., Revere, L., Sharath, S., & Kougias, P. (2017). Implications of Clinical Documentation (In) Accuracy: A Pilot Study Among General Surgery Residents. Hospital Topics, 1-5.
  • Thomas, J. (2009). Medical records and issues in negligence. Indian Journal of Urology, 25(3), 384.
Course Summary
Available credit: 
  • 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
Course opens: 
06/01/2021
Course expires: 
05/31/2024
Part of: 
Baptist Health Medical Staff Annual Credentialing Requirements

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.

Disclosure Policy and Disclaimer

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.

Available Credit

  • 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
Please login or register for a Baptist Health CME account to take this course.

Required Hardware/Software

PC/Mac Users
PC/Mac Users

This site is supported on the most recent stable releases of the following browsers:

Click Here to Download Google Chrome
Google Chrome		Microsoft Edge
Microsoft Edge		Safari
Safari		Moxilla Firefox
Mozilla Firefox
Internet Explorer

Attention: Internet Explorer Users
This site offers limited support for Internet Explorer 11 (IE11). When using IE11, you will be prompted to download course videos instead of viewing them in the browser. After the course video downloads, the recordings will play.

Mobile Users
Mobile Users

This site is supported on the following mobile devices:

  • Apple iOS mobile devices running iOS 10 or later
  • Android mobile devices running Android 4.4 or later, with the latest release of Google Chrome or Mozilla Firefox
Technical Support
Technical Support

If you are experiencing technical difficulties or have received an error message, please send an email to CME@baptisthealth.net and include a print screen of the error message, your browser name and version, username and URL where the error occurred. You can expect a response within 48 hours.