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

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.

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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.

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COURSE LECTURER

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Dr. Richard Kelly (see Faculty Bio) >>>

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