Webinar on Demand - Documentation: The Good, The Bad, and The Ugly

Webinar on Demand - Documentation: The Good, The Bad, and The Ugly

Webinar On Demand
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Online Course | Specialties: Family Medicine, Hospitalist, Internal Medicine, Pediatrics
Released: 8/27/2020
Expires: 8/26/2022
Max Credits: 1.0
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Ellen Epstein Cohen, JD
Adler, Cohen, Harvey, Wakeman, and Guekguezian, LLP
Boston, MA
Presenter Bio
Ellen Epstein Cohen is an experienced trial attorney, having successfully defended clients in both state and federal courts for almost 35 years. Ellen also has a strong interest in alternative dispute resolution and has participated in innumerable mediations and arbitrations. Ellen focuses her practice primarily on the representation of physicians, nurses, and the full spectrum of healthcare providers in the defense of medical malpractice claims and before the boards of registration that govern licensed healthcare professionals. The professional liability aspect of Ellen's practice includes all medical specialties and cases that range from involving only minor injuries to catastrophic injuries and death. In addition, Ellen works with clients to develop strategies and practices to help minimize risk by avoiding potential problems. She also shares her malpractice risk management knowledge through lectures and panel discussions before professional organizations.

Activity Planners
Kathryn Schaefer, MSN, RN, CPHRM
Senior Manager, Accreditation and Compliance
East Lansing, MI

Susan Kuhn, MHSc
Manager, Education Strategy and Content
Baltimore, MD

Learning Objectives
Upon completion, participants should be able to:

  • Identify potential pitfalls in healthcare documentation practices.
  • Enable learners to rectify weaknesses in documentation systems.
  • Describe best practices in medical record documentation.

Target Audience
This webinar is intended for physicians, nurses, risk managers, quality managers, patient safety officers, performance improvement staff members, administrators, pharmacists, legal counsel, front-line staff members, and any other interested parties.
Statement of Need
The patient medical record is an enduring reflection of care that evolves over time and provides information for making clinical decisions, conducting research, and performing quality assurance. Neglecting to document important details can lead to adverse patient outcomes and leave providers and organizations open to malpractice lawsuits. Incomplete or inaccurate documentation of patient encounters can expose providers and their organizations to the risk of litigation, potential loss of licensure, lost revenue, and settlement fees, and, perhaps most importantly, may result in poor patient care. For these reasons, healthcare providers need to be familiar with real-world common documentation pitfalls and their consequences, as well as best practices for medical documentation.

Providership Statement
Provided by Med-IQ, a Coverys company.
Accreditation/Designation Statements
Med-IQ is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Med-IQ designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Med-IQ is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This nursing activity has been approved for up to 1.0 contact hour.

Other healthcare professionals who successfully complete the activity will receive a Statement of Participation indicating the maximum credits available.

Instructions to Receive Credit
To receive credit, review the introductory CME/CNE material, watch the webinar, and complete the evaluation.

Initial Release Date: August 27, 2020
Expiration Date: August 26, 2022
Estimated Time to Complete This Activity: 60 minutes

Disclosure Policy
Med-IQ requires any person in a position to control the content of an educational activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines “relevant financial relationships” as those in any amount occurring within the past 12 months, including those of a spouse/life partner, that could create a conflict of interest (COI). Individuals who refuse to disclose will not be permitted to contribute to this CME activity in any way. Med-IQ has policies in place that will identify and resolve COIs prior to this educational activity. Med-IQ also requires faculty to disclose discussions of investigational products or unlabeled/unapproved uses of drugs or devices regulated by the US Food and Drug Administration.

Disclosure Statement
The content of this activity has been reviewed and approved for compliance. The faculty and contributors have indicated the following financial relationships, which have been resolved through an established COI resolution process, and have stated that these reported relationships will not have any impact on their ability to give an unbiased presentation.

Ellen Epstein Cohen, JD has indicated no real or apparent conflicts.

The reviewers and other activity planners have no financial relationships to disclose.
Statement of Evidence-Based Content
Educational activities that assist physicians in carrying out their professional responsibilities more effectively and efficiently are consistent with the ACCME definition of continuing medical education (CME). As an ACCME-accredited provider of CME, it is the policy of Med-IQ to review and ensure that all the content and any recommendations, treatments, and manners of practicing medicine in CME activities are scientifically based, valid, and relevant to the practice of medicine. Med-IQ is responsible for validating the content of the CME activities it provides. Specifically, (1) all recommendations addressing the medical care of patients must be based on evidence that is scientifically sound and recognized as such within the profession; (2) all scientific research referred to, reported, or used in CME in support or justification of a patient care recommendation must conform to generally accepted standards of experimental design, data collection, and analysis.
Med-IQ is not liable for any decision made or action taken in reliance upon the information provided through this activity.
Contact Information
For questions or comments about this activity, please contact Med-IQ. Call (toll-free) 866.858.7434 or email

For assistance with connecting to the webinar, please call 800.313.5888, and choose option 7.

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The information provided through this activity is for educational purposes only. This information is intended to provide general guidelines for risk management. It is not intended and should not be construed as legal or medical advice.

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Here are the key takeaways from this activity. More details and examples, plus an opportunity to receive credit, are available at the "Get Credit" button below.

Detailed and timely documentation of patient care within the medical record is critical for making clinical decisions, conducting research, and performing quality assurance. Conversely, failure to document important details can lead to adverse patient outcomes and leave providers and organizations open to malpractice lawsuits. Through both didactic discussion and tales from the courtroom, this activity highlights the following benefits and pitfalls of documentation:

  • Electronic health record (EHR) systems have many benefits over paper records, including eliminating legibility issues; enhancing access to information, reminders, and alerts (eg, drug allergies); and allowing for improved communication among providers and between providers and patients.
  • However, EHRs are not without pitfalls, including the carrying forward of outdated or inaccurate information by use of the copy and paste functions, template limitations, increased potential for HIPAA violations, and inaccuracies resulting from the failure to amend entries when appropriate.
  • EHR audit trails and revision histories can make or break the legal defense by providing chronological evidence of who accessed the EHR, when, from where, and what was done within the EHR.
  • To mitigate the risks associated with documentation, healthcare professionals must be able to understand and answer the following questions:
    • What is factual content versus editorial content?
    • How do you document texts and emails, and what are the appropriate methods to communicate with patients electronically?
    • Where and how should telehealth visits be documented in the patient’s medical record?
    • Should the telehealth visit be video-recorded and saved as part of the EHR?
    • How should informed refusal be documented?

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Unless otherwise indicated, photographed subjects who appear within the content of this activity or on artwork associated with this activity are models; they are not actual patients or doctors.

The information provided through this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient’s medical condition.

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