Page 3 - Risk Reduction Series - Documentation Essentials (Part One)

Faculty and Authors

This course was developed by SVMIC’s Risk Education and
Evaluation Department: Shelly Weatherly, JD, VP; Julie Loomis,

RN, JD, AVP, Risk Education Program and Development;
Jeff Woods, JD, Director of Risk Education Program and
Development. Reviewed by Michael McAdoo MD, on September

21, 2020.

Overview
This course outlines and discusses the essentials and
basic principles of documentation to guide physicians and

other practitioners to create a more concise, objective, and
accurate medical record. Utilizing case examples to illustrate

documentation issues which presented challenges to the
defensibility of a lawsuit, you will identify documentation
strategies to create a more accurate, relevant, and defensible

medical record.

Course Objectives
Upon completion of this course, participants should be able to:

1. Utilize documentation strategies to create a more accurate,

relevant, and defensible medical record

2. Identify risks and benefits of electronic medical

documentation, including the use of templates, cloned
notes, copy & paste, and auto-population

3. Recognize top documentation issues that have been
identified through medical record audits