Documentation is essential to patient care. It is a valuable tool used for communication for patient care, is one of the basic risk management tools used in the defense of licensing complaints or malpractice claims. Documentation serves many purposes legal, regulatory, and clinical.
This webinar will explain and review basic documentation principle and describe how documentation is used for defense in litigation. It will also identify risks associated with documentation in the electronic health record and review best practices for documentation.
Course References
- American Psychiatric Association. Online Practice Handbook. www.psychiatry.org/psychiatrists/practice/practice-management/starting-a-practice/online-practice-handbook
- Psychiatric News. Documentation: Your Very Best Defense. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.04.3.36
- Health Information Privacy –U.S. Department of Health and Human Services https://www.hhs.gov/hipaa/index.html
Educational Objectives
- Describe how documentation is used for defense in litigation.
- Explain basic documentation principles.
- Identify risks associated with documentation in the electronic health record.
- Apply best practices for documentation in the medical record.
Target Audience
Psychiatrists, Residents/Fellows
Estimated Time to Complete
Estimated Duration: 60 minutes
Program Start Date: January 1, 2024
Program End Date: January 1, 2027
Participants who wish to earn AMA PRA Category 1 Credit™ may do so after completing all sections of the course including the evaluation. After evaluating the program, course participants will be provided with an opportunity to claim hours of participation and print an official CME certificate (physicians) or certificate of participation (non-physicians) showing the completion date and hours earned.
Continuing Education Credit
In support of improving patient care, the American Psychiatric Association is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
The APA designates this live activity for a maximum of 8 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Faculty and Planner Disclosures
The American Psychiatric Association adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Medical Education. Any individuals in a position to control the content of a CME 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.
Presenter:
- Cara Staus, CPHRM, FASHRM, Assistant Vice President Risk Management Group. Reports no financial relationships with commercial interests.
Program Planners:
- Jennifer Hackett, AVP, Risk Managment Group, AWAC Services. Reports no financial relationships with commercial interests.
- Rajesh Tampi, MD, MS, Professor (Tenured) and Chairman, Department of Psychiatry, Creighton University School of Medicine. Reports no financial relationships with commercial interests.
Accessibility for Participants with Disabilities
The American Psychiatric Association is committed to ensuring accessibility of its website to people with disabilities. If you have trouble accessing any of APA’s online resources, please contact us at 202-559-3900 for assistance.
Technical Requirements
This internet-based CME activity is best experienced using any of the following:
- The latest and 2nd latest public versions of Google Chrome, Mozilla Firefox, or Safari
- Internet Explorer 11+
This Web site requires that JavaScript and session cookies be enabled. Certain activities may require additional software to view multimedia, presentation, or printable versions of the content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Adobe Acrobat Reader, Microsoft PowerPoint, and Windows Media Player.
Optimal System Configuration:
- Browser: Google Chrome (latest and 2nd latest version), Safari (latest and 2nd latest version), Internet Explorer 11.0+, Firefox (latest and 2nd latest version), or Microsoft Edge (latest and 2nd latest version)
- Operating System: Windows versions 8.1+, Mac OS X 10.5 (Leopard) +, Android (latest and 2nd latest version), or iOS/iPad OS (latest and 2nd latest version)
- Internet Connection: 1 Mbps or higher
Minimum Requirements:
- Windows PC: Windows 8.1 or higher; 1 GB (for 32-bit)/2 GB (for 64-bit) or higher RAM; Microsoft DirectX 9 graphics device with WDDM driver; audio playback with speakers for programs with video content
- Macintosh: Mac OS X 10.5 or higher with latest updates installed; Intel, PowerPC G5, or PowerPC G4 (867MHz or faster) processor; 512 MB or higher RAM; audio playback with speakers for programs with video content
For assistance: Contact educme@psych.org for questions about this activity | Contact learningcenter@psych.org for technical assistance