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Publication (PDF)

Avoiding Common Documentation Errors


2024 Reporter Q1
Credit(s): 1 AMA PRA Category 1 Credits™ (Enduring material)
1 Medical Ethics and/or Professional Responsibility
Course Number: 2917
Original Program Date: March 15, 2024
Access: Available until March 15, 2027
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Categories: Risk Management, CME, Documentation ... (show more)
Categories: Risk Management, CME, Documentation, EMR/EHR, The Reporter (show less)
Release Date: March 15, 2024
Expiration Date: March 15, 2027

This article will review what constitutes a poor vs. quality patient record; how to avoid common documentation errors; and risk management considerations when using electronic health records (EHRs) and scribes. 


Please note that this CME activity does not meet TMLT's discount criteria. Physicians completing this CME activity will not receive a premium discount.
 
Course Objectives:

Upon completion of this course, the participant should be able to:
  • describe good medical record documentation practices;
  • summarize how to avoid common documentation errors;
  • discuss the unique documentation risks associated with using electronic health records; and
  • define the recommended components of documentation policies and protocol.

CME Credit Statement:
The Texas Medical Liability Trust is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Texas Medical Liability Trust designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.
 
Test: 
To receive CME credit, physicians should complete the test questions that follow the activity. A passing score of 70% or better earns the physician 1 CME credit.
 
Ethics Credit Statement:
This course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.
 
Disclosure:

Wayne Wenske and Tanya Babitch have no relevant financial relationship(s) with ineligible companies to disclose.  TMLT staff, planners, and reviewers have no relevant financial relationship(s) with ineligible companies to disclose.
 
Disclaimer:
The information and opinions in the online CME courses should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor its affiliates are engaged in rendering legal services.
 
Target Audience:
This 1-hour activity is intended for physicians of all specialties who are interested in learning more about establishing and maintaining quality patient records and avoiding common documentation errors.

Copyright © 2024 TMLT. All rights reserved. The content of this website is copyrighted by TMLT unless otherwise indicated. Content may not be copied, reproduced, or transferred in any way without the written consent of TMLT. 
http://www.tmlt.org/contact/copyright-and-privacy-policy
1 AMA PRA Category 1 Credits™ (Enduring material)   Texas Medical Liability Trust is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Texas Medical Liability Trust designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

1 Medical Ethics and/or Professional Responsibility   This course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.

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Mon - Fri 8:00am to 5:00pm Central time, dial (800) 580-8658 x5050
For an after-hours technical questions only, dial (877) 880-1335
Email Us

CCPA & GDPR