Medical Record Keeping | 22 CME

Medical Record Keeping | 22 CME  

Course Description

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 a medical record keeping course either by hospitals or by regulatory or licensing agencies.

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 when to maintain confidentiality of patient information

·  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 essential to the proper care and treatment of patients. Medical record keeping is only a small part of any health education curriculum and many health care professionals, despite handling medical records regularly, do not fully understand the elements and purpose of medical record keeping. The consequences of this lack of understanding can be devastating and may include the loss or curtailment of hospital privileges as well as more dire consequences like censure, probation, or even the loss of medical license as a result of licensing board action. Some practitioners may even face the prospect of a legal action and, at the extreme, imprisonment. This educational program will provide health care practitioners with up-to-date solutions and “best practices” for the medical record keeping issues clinicians face daily.

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.