The Importance of Medical Documentation

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NOTE: This course is mandatory for advanced practice providers new to the Baptist Health Medical Staff. It is required at initial appointment only.

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.

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.

Target Audience

Medical Staff Physicians, Advanced Practice Registered Nurses, Physician Assistants/Physician Associates, Pharmacists, Respiratory Therapists and Occupational Therapists.

Learning Objectives

  • Evaluate the importance of accurate medical documentation in ensuring compliance with regulations and improving patient care outcomes.
  • Develop comprehensive documentation that supports the intensity of service, plan of care, and expected duration of treatment for patients.
  • Implement the best practices for documenting medical necessity, severity of illness, and intensity of service to ensure compliance with Medicare requirements.
Additional information
Bibliography: 
  • Centers for Medicare & Medicaid Services (CMS). (2023). Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and policy changes and fiscal year 2024 rates. Federal Register, 88(159), 55000-55200. 
  • Centers for Medicare & Medicaid Services (CMS). (2014). Inpatient Admission and Medical Review Criteria. Medicare Learning Network® (MLN) Connects™ National Provider Call. Retrieved from 
  • Kartchner, B. (2024, October 23). The Two-Midnight Rule: All About the Expectation. ICD10monitor. 
  • MedLearn Media. (2024). Understanding the Finer Points of the Two-Midnight Rule. RACmonitor. 
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: 
12/01/2024
Course expires: 
11/30/2027

Sharon Miles MSN, R.N.
Corporate Director of Utilization and Denials Management
Baptist Health South Florida
Miami, Florida

Aimee Jones, MSN, R.N.
Denial and Appeals Coordinator 
Concurrent Denial Prevention
Baptist Health South Florida
Miami, Florida

Milly Selgas, R.N. 
Corporate V.P. of Clinical Log EBC Case Management 
Baptist Health South Florida 
Miami, Florida

Due to the non-clinical nature of the content discussed, the authors, physician advisors,  conference directors, and planners have no relevant financial relationships to disclose. This CME activity will not cover content that would involve products or services of commercial interest. Therefore, no opportunity exists for a conflict of interest based on the financial relationships of faculty and those persons in control of content. Since these relationships are not relevant, no disclosure information was collected.
 

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

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Mobile Users
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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.