Course description

The fundamentals of documentation remain the same as always: every healthcare professional has been trained extensively in the basic requirements. However, with the landscape of healthcare always developing and changing, the way you apply these fundamentals must adjust in a variety of ways. 

For example, are you aware of how documentation of telemedicine patient encounters differs from that of in-person encounters? How is it the same? 

When your practice receives paperwork that needs to be incorporated into the medical record, do you have a system for ensuring it’s complete and signed off on properly before scanning it in?

Are you careful in your use of templates and other EMR documentation tools?

In this course, we will examine these and other current challenges in medical record documentation. We will discuss the patient safety risks posed by these documentation hurdles, as well as practical steps you can take to reduce or eliminate these risks.

Learning objectives

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

• Identify major documentation challenges in the current healthcare environment
• List the impacts to patient safety posed by these challenges
• Describe the steps a healthcare professional can take to mitigate the risks posed by documentation errors

Target audience

Physician and clinician policyholders

Disclosure

There are no relevant financial relationships with ACCME-defined commercial interests for anyone who was in control of the content of this activity.

CME Information

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 Illinois State Medical Society and ISMIE Mutual Insurance Company. The Illinois State Medical Society is accredited by the ACCME to provide continuing medical education for physicians.

The Illinois State Medical Society designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit^™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The Illinois Nurse Practice Act rules deem CME credit provided by approved sponsors as acceptable to fulfill nursing continuing education requirements for licensure. Nurses may claim one contact hour per unit of CME in the state of Illinois.

MOC information

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 Medical Knowledge MOC points and patient safety MOC credit in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.