Medical Record Keeping | 22 CME

Medical Record Keeping | 22 CME  

Course Description

​This Medical Record Keeping course, approved by the Medical Board of California, is designed for physicians, nurse practitioners, physician assistants, nurses, and attorneys seeking to enhance their medical record keeping skills. Through a combination of lectures, case studies, discussions, and individualized records review, this course equips participants with a comprehensive understanding of the laws and regulations governing medical record keeping. It empowers them with the necessary tools to maintain compliant medical records ensuring adherence to federal, state, and local laws. This course is particularly valuable for healthcare professionals who require additional or remedial training as mandated by hospitals, regulatory agencies, or licensing bodies.

Learning Objectives

At the conclusion of this activity, participants will be better able to:

·  Identify the purpose and standards of medical record keeping

·  Minimize exposure to litigated issues through proper documentation

·  Assess conditions when confidentiality of patient information must be maintained

·  Identify special medical record requirements for psychiatric, HIV, and other sensitive information

·  Distinguish when medical records may or should be disclosed to a third party

·  Recognize consequences of improper disclosure of medical information

·  Classify intentional and negligent spoliation of evidence

·  Convey how medical records show fulfillment of legal obligations

·  Describe how medical record errors increase professional liability

Needs Assessment

Effective medical record keeping is vital for patient care and extends beyond mere documentation. While it may be a small part of healthcare education, medical records serve as more than just records of a patient's condition. They are essential tools for communication and, significantly, legally binding documents. Failing to grasp the multifaceted role of medical records can lead to severe consequences for practitioners , including loss of hospital privileges, censure, probation and even the revocation of medical licenses. In some cases, inadequate record keeping can result in legal action and imprisonment. This program provides healthcare practitioners with the knowledge and best practices to maintain medical records, ensuring safe and effective practice while adhering to federal, state, and hospital regulations.

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.