Medical Record Documentation: The Good. The Bad. The Ugly.
Speaker
Kathryn S. “Missy” Mosely
Description
The medical record is at the center of litigation of medical malpractice cases. The contents of the record, or the lack thereof, can either provide supportive documentation or create the appearance of lack of attention and care. This seminar reviewed best practices for medical record creation including a discussion of documentation regarding the “difficult patient,” chain-of-command issues, and disclosures. Provider approved by the California Board of Registered Nursing, Provider number 12205 for 1 contact hours. This meeting has been approved for 1 contact hour of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.
Online Education Evaluation and Attestation of Attendance Form
Learning Objectives
At the end of the webinar, the participant should be able to:
- Demonstrate understanding of the importance of documentation accuracy, relevancy, completeness, and timeliness.
- Understand chain of command and the influence on charting: how to communicate and document when findings differ.
- Understand best practices and the importance of proper documentation in anticipation of litigation.
- Include transparency and disclosure in documentation.
- Evaluate areas where implicit bias can influence documentation and patient safety.