Medical Record Keeping | 22 CME

Medical Record Keeping | 22 CME  

This course is designed for professionals who have the need or desire to improve their understanding of medical record keeping, which meets standards, laws, and regulations pertaining to medical record keeping, for improved medical care, delivery of services, and clear and accurate communications. It is specifically developed for professionals who have been found deficient in medical record keeping either by hospitals or by regulatory agencies.​

Target Audience

This course is suitable for physicians, dentists, veterinarians, chiropractors, nurse practitioners, physician assistants, nurses, mental health providers, EMT’s, physical therapists, students, and a wide variety of other clinicians. This course applicable to attorneys.​ 

Learning Objectives

​Upon completion, clinicians should be able to: 

• Describe how to maintain compliance with laws regarding medical record keeping
• Understand and implement the regulations and laws regarding medical record keeping
• Improve documentation in support of appropriate billing codes, regulations, and expectations
• Document with clarity to reduce misinterpretation and errors
• Provide improved documentation for risk management
• Apply improved skills for maintaining electronic medical records
• Comply with standards of practice, codes of ethics, and state statutes
• Create and implement a plan that includes strategies, safeguards, and systems to reduce the risk of relapse and improve accountability.

Needs Assessment

Medical record keeping is essential to the health and welfare of patients. Medical record keeping is only a small part of any health education curriculum and many health care professionals do not fully understand the elements of medical record keeping. The consequences of not understanding the elements of medical record keeping can be devastating, including censure, loss of hospital privileges, probation, loss of medical license, and, in extreme instances, imprisonment.This educational program will attempt to provide health care practitioners with “best practices” and practical solutions for many of the medical record keeping issues facing clinicians in their practices. This program is designed for attending and resident physicians, dentists, veterinarians, chiropractors, nurse practitioners, physician assistants, and nurses. Other healthcare professionals who may benefit from this activity are medical students, mental health providers, EMT’s, physical therapists, attorneys, and undergraduate students who wish to learn more about medical ethics and professionalism.​

Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of California, Irvine School of Medicine and the Academy of Ethics & Legal Medicine. The University of California, Irvine School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Designation Statement

The University of California, Irvine School of Medicine designates this live activity for a maximum of 22 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.