Page 3 - Part One Risk Reduction Series - Documentation
P. 3
Overview
This course outlines and discusses the basic principles of
documentation for both paper and electronic records which will
help providers create a more concise, objective and descriptive
record. Utilizing case examples to illustrate documentation issues
which presented challenges to the defensibility of a lawsuit, you
will learn documentation strategies to create a more accurate,
relevant and defensible medical record.
Course Objectives
At the end of this course, the participant will be able to:
1) Better describe patient presentations by documenting in
concise, objective terms.
2) Utilize documentation strategies to create a more accurate,
relevant and defensible medical record.
3) Identify risks and benefits of electronic medical
documentation, including the use of templates, cloned notes,
copy & paste and auto-population.
4) List the top three documentation issues that have been
identified through medical record audits.
