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Medical Record Charting Fundamentals

Learn and understand basic medical record charting fundamentals and the impacts of HIPAA on medical chart access.

During this topic we will cover the basics of medical charting, including defining the scope of medical charting, discussing the history and future of EMR, and covering the basic do's and don'ts of charting in both written and EMR format. We will cover charting best practices, including charting methods and tips and tricks designed to protect providers from lawsuits. We will consider the impacts of HIPAA on chart access and chart retention practices, as well as strategies to follow in the event of a violation. We will also discuss examples of how charting is used in litigation, preparing you for tactics used by plaintiff's attorneys in reviewing charting and exploiting gaps in charting.

90 minutes
Certificate of Completion
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Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

The Elements of a Medical Chart

  • What Is a Medical Chart: Definitions
  • What Is EMR?
  • History of EMR
    • HIPAA / HITECH

Best Practices of Medical Charting

  • Joint Commission Requirements
  • Basic Goals of Documentation
  • Consideration of the Audience
  • Gatekeeper Statutes
  • How to See Documentation as a Defense
  • Beyond the S-O-A-P Note
  • Charting Do's and Don'ts
    • Basics
    • Who Can Add to the Chart
    • How Do You Update or Correct the Chart?
    • Documentation of Emerging Evaluations / Diagnoses
    • EMR Prefills, Check Boxes and Cutting and Pasting
  • Case Examples
    • Uses in Deposition

Communication: Documentation of Contacts With Patient, Family, Staff and Colleagues

  • Communication Matters
  • How to Tell the Story
  • Failure to Follow up by Doctor
  • Documentation of Failures to Return for Care / Follow up by Patient
  • Curbside Consultations
  • New Forms of Communication
    • Emails
    • Text
    • Voicemails and Private Cell Phones
    • Integrated Portals
    • Social Media
    • Do's and Don'ts

How EMR Has Changed Medical Practice

  • Notice
  • Creation of Physician - Patient Relationship
  • Issues
    • Information Overload
    • Issues With Dictation and Review
    • Incompatible Systems
    • Audit Trails
    • GPS Data
    • In Person Document Reviews

HIPAA Issues

  • HIPAA Overview - What Is HIPAA?
  • Impact of HIPAA: Lost Charts / Data Loss
  • Impact of HIPAA: Provider Access
  • How to Respond to a Known or Suspected Breach
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Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

OnDemand Course

This course was last revised on November 7, 2019.

Call 1-866-352-9540 for further credit information.

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

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Why Lorman?

Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Stuart Berman

Stuart Berman

Barker, Castro & Steinback, LLC

  • Partner at Barker, Castro & Steinback, LLC in Chicago
  • Practice focuses on medical malpractice, long-term care defense, and the formation of captive insurance companies; he defends hospitals, medical centers, nursing homes, physician groups, individual physicians and nurses in medical malpractice, and long-term care negligence cases
  • Has particular expertise in cases involving complex and catastrophic losses, product liability, and compliance issues
  • Consults and advises hospitals and other healthcare facilities on restructuring risk management processes and compliance issues
  • National supervising counsel for two national insurance collectives and works to assist doctors and hospitals in forming captive insurance companies, risk retention groups, and risk purchasing groups
  • Frequently speaks to medical and legal professionals regarding topics related to healthcare litigation and has written or co-written multiple publications and has written, edited, presented, and/or co-presented multiple lectures covering a range of topics in medical malpractice
  • Graduate, Chicago-Kent College of Law; undergraduate, Bates College
  • Can be contacted at [email protected] or 312-447-3212
Kelly Pachis

Kelly Pachis

L&G Law Group LLP

  • Associate attorney at Lowis & Gellen LLP
  • Concentrates her practice in civil litigation with an emphasis on medical malpractice defense, representing hospitals, nursing homes and physicians in various specialties, including internal medicine, obstetrics & gynecology, orthopedic surgery, general surgery, anesthesiology, urology, and neurosurgery
  • Experience in all stages of the litigation process, from depositions to motion practice and trial; she second chaired her first case at trial in May 2013, resulting in a verdict for the defendant neurosurgeon
  • Has been recognized as an Emerging Lawyer by Leading Lawyer Magazine, which recognizes the top 2% of lawyers under 40 years old
  • Admitted to the Illinois Bar in 2011 and to the U.S. District Court for the Northern District of Illinois in 2013; an active member of the Illinois Association of Defense Trial Counsel, Chicago Healthcare Risk Management Society, and The John Marshall Law School Alumni Advisory Board she also serves as Second Vice President of the Bohemian Lawyers’ Association of Chicago
  • J.D. degree, The John Marshall Law School; B.A. degree, with honors, with a major in journalism and a minor in political science, University of Iowa
Patrick Viktora

Patrick Viktora

L&G Law Group LLP

  • Associate attorney at Lowis & Gellen LLP
  • Concentrates his practice in civil litigation with an emphasis on medical malpractice defense, representing physicians, nurses, and hospitals in complex litigation
  • Also has experience handling cases involving pharmaceutical liability, premises liability, and claims of physician-patient sexual abuse; in addition to handling all stages of litigation, he also handles pre-suit investigations of potential high risk claims
  • Has been recognized as an Emerging Lawyer by Leading Lawyer Magazine, which recognizes the top 2% of lawyers under 40 years old
  • Admitted to practice in Illinois and is an active member of the Chicago Healthcare Risk Management Society
  • J.D. degree, with a certificate in business law, magna cum laude, DePaul University College of Law; B.A. degree in political science, University of Illinois
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Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

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Product ID: 406580
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