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
Medical record keeping is fundamental to the proper care and treatment of patients. Although medical record keeping is only a small part of any health education curriculum, the importance of medical records extend far beyond documenting the patient's condition. The medical record documents not only the patient's illness and response to therapy, but it also serves as a tool for communication and, most importantly, constitutes a legal document. The lack of understanding of the many roles of the medical record may have devastating consequences on the practitioner such as curtailment or loss of hospital privileges, censure, probation and even loss of medical license. In some cases, improper medical record keeping can lead to legal action that can result in imprisonment. This educational program gives the health care practitioner the knowledge and best practices for maintaining medical records that are compliant with federal, state, and hospital regulations so practitioners can practice safely and effectively.
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.
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.
This Medical Record Keeping course has been reviewed and approved by the Medical Board of California and is designed for medical and legal professionals, including physicians, nurse practitioners, physician assistants, nurses, and attorneys who wish to improve their skills in medical record keeping. Utilizing didactic lectures, case studies, written questions, and classroom discussions, the course provides participants with a comprehensive working understanding of the laws and regulations relating to medical record keeping and gives them the tools needed to keep their medical records compliant with federal, state, and local laws. This course has been developed in accordance with the standards of the Medical Board of California and is appropriate for physicians who have been found in need of additional or remedial training either by hospitals, regulatory agencies, or licensing bodies.
Medical Record Keeping | 22 CME
Live Online Course