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Clinical Documentation after HITECH: It's Back to Risk Management Basics

Activity Type:

  • On Demand

Release Date: 9/6/2015

Expiration Date: 9/6/2019

  • AMA PRA Category 1: 1
  • Participation: 1



Medical record documentation is an essential component in psychiatric practice. It is also a critical component when defending a medical malpractice claim against a psychiatrist. This course identifies the importance of a complete medical record, development of policies and procedures and identifies clinical documentation best practices to reduce risk.


  • General Member - Free
  • Resident-Fellow Member - Free
  • Medical Student Member - Free
  • Non-Member - $25.00

Educational Objectives

  • Understand the importance of formal policies and procedures for medical record documentation
  • Establish and implement protocols for the security of protected health information
  • Minimize risk by adopting best practices to avoid professional liability claims
  • Understand what many/may not need to be documented
  • Understand the medical record as a legal document

Target Audience

Psychiatrists and Residents/Fellows

Estimated Time to Complete

Estimated Duration: 1 Hour
Project Start Date: September 6, 2015
Project Review Date: September 2018
Project End Date: September 6, 2019

How to Earn Credit

Participants who wish to earn AMA PRA Category 1 Credit ™ or a certificate of participation may do so by completing all sections of the course including the evaluation. A multiple choice quiz is provided based on the content. A passing score of 50% must be achieved. Retakes are available for the test. After evaluating the program, course participants will be provided with an opportunity to claim hours of participation and print an official CME certificate showing the date of completion and hours earned. 

Continuing Education Credit

The American Psychiatric Association (APA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The APA designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Faculty and Planner Disclosures

Presenter and 2018 Review:

  • Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM, Vice President, Psychiatric and Professional Liability Risk Management Group, AWAC Services Company, Inc. | Disclosure: Reports no financial relationships with commercial interests

Program Planners:

  • Jon Fanning, MS, CAE, Chief of Membership and RFM-ECP, American Psychiatric Association | Disclosure: Reports no financial relationships with commercial interests
  • Tristan Gorrindo, MD, Director of Education, American Psychiatric Association | Disclosure: Reports no financial relationships with commercial interests
  • Ricardo A. Juarez, MS, Associate Director, International Affairs, American Psychiatric Association | Disclosure: Reports no financial relationships with commercial interests
  • Trang Smith, Former Associate Director, Membership Development, American Psychiatric Association | Disclosure: Reports no financial relationships with commercial interests

Hardware/Software Requirements

Hardware/Software Specifications: 
This internet-based CME activity is best experienced using Internet Explorer 8+, Mozilla Firefox 3+, Safari 4+. 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, Microsoft PowerPoint, and Windows Media Player.

Optimal System Configuration:

Flash Player: Adobe Flash Player 10.1+ 
Browser: Firefox 3+, Internet Explorer 8.0+, Safari 4.0+, or Google Chrome 7.0+ 
Operating System: Windows XP+ or Mac OS X 10.4+ 
Internet Connection: 1 Mbps or higher

Minimum Requirements:
Windows PC:
500-MHz Pentium II; Windows XP or higher; 128 MB RAM; Video Card at least 64MB of video memory; Sound Card at least 16-bit; Macromedia Flash Player 10 or higher, audio playback with speakers for programs with video content; Firefox 1.1+, Internet Explorer 7.0+, Safari 1.0+, Google Chrome, or Opera
Mac OS X 10.3 or higher with latest updates installed; 1.83MHz Intel Core Duo or faster; RAM: 128MB or more; Video Card: at least 64MB of video memory; Sound Card: at least 16-bit

For assistance: Contact educme@psych.orgfor questions about this course  |  Contact for technical assistance