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. In claims management, the medical record is the only way to prove that the treatment was carried out properly. Oscar J. Cabanas, J.D., will examine the role of medical record documentation as an important medical-legal function in risk management.

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 Providers and Clinical Employees.

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: 
  • 2.00 AMA PRA Category 1 Credit™
  • 2.00 General certificate of attendance
  • 2.00 Nurse Practitioners
  • 2.00 Florida Board of Nursing
Course opens: 
10/01/2017
Course expires: 
10/01/2019

Mark J. Hauser, M.D., FACP, FCCP
President, Medical Staff Affairs
Baptist Hospital of Miami

Oscar J. Cabanas, J.D.
Wicker, Smith, O'Hara, McCoy & Ford P.A.
Coral Gables, Florida

Mark J. Hauser, M.D., FACP, FCCP, and Oscar J. Cabanas, J.D., indicated that neither they nor their spouses/partners have relevant financial relationships with commercial interest companies, and they will not include off-label or unapproved product usage in their presentations or discussions.

Non-faculty contributors and others involved in the planning, development and editing/review of the content have no relevant financial relationships to disclose.

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 2 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Available Credit

  • 2.00 AMA PRA Category 1 Credit™
  • 2.00 General certificate of attendance
  • 2.00 Nurse Practitioners
  • 2.00 Florida Board of Nursing
Please login or register for a Baptist Health CME account to take this course.

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