Practice Pearls: Documentation and Med-Mal Prevention (Online)

Tuesday, March 21, 2023, 6:00 AM - Thursday, March 21, 2024, 5:00 PM


AMA PRA Category 1 Credits™ (1.00 hours), Non-Physician Attendance (1.00 hours)

For medical practitioners, charting and documentation is a pain. But medical malpractice lawsuits (and possibly an accompanying licensing investigation and administrative complaint) are a much bigger pain! It is every practitioner’s duty to keep a full and complete medical record by law. Under-charting, over-charting, sloppy/inaccurate charting, missing charting, charting by exception, late charting, and altered records are almost always at the heart of, or at least a major contributing factor in the fi ling of medical practice cases. Learning to avoid documentation pitfalls without increasing your workload will save you a lot of pain and grief down the road. But, in the event you receive the dreaded Notice of Intent anyway, you will at least make your med mal defense attorney and insurer much happier and make the plaintiff ’s attorney much more nervous. Judges and juries love nothing better than a good clear record to provide a “no cause” verdict in favor of the practitioner. Join us to learn some practice pearls that can be put into immediate use to improve your charting and documentation.

1. Awareness and understanding that the medical record is a legal record and an historical record/timeline of evaluation, diagnosis, and treatment.
2. Describe and translate necessary medical information and procedures into clear, accurate, useful, and legally defensible language in the medical record.
3. Apply the information learned in the first two learning objectives to create documentation that will serve as effective preventative or courtroom evidence of the patient’s evolving condition, clinical impression/diagnosis, treatment, response to treatment, prognosis, and the care providers involved.
4. Internalize and apply simple charting and documentation methods of reducing medical malpractice liability.

Spectrum Health Hospitals 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.

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Spectrum Health adheres to ACCME Criteria, Standards and Policies regarding industry support of continuing medical education. Disclosure of faculty and their commercial relationships will be made prior to the activity.

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Spectrum Health adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.