Best Documentation Practices: The Good, The Bad, and The Risky

$189.00

6 months of access to Best Documentation Practices: The Good, The Bad, and The Risky

Presentation run time is 33 minutes.

After participating in this activity participants will be able to:

  1. Recognize why we document
  2. Recognize challenges of documentation in the electronic environment
  3.  Perform optimal documentation
  4. Avoid risky documentation practices

Description

Release Date: December 1, 2019
Expiration Date: November 30, 2022

Faculty:
Erica E. Remer, MD, CCDS
President and Founder
Erica Remer, MD, Inc.
Dr. Remer reports no financial relationship with a commercial interest relevant to this activity.

Target Audience
This continuing medical education activity is intended for physicians, physician assistants, nurse practitioners, residents, and medical students. It will benefit any healthcare provider who documents in the medicolegal record and wants to optimize their communication, quality metrics, and reimbursement.

Media
Recorded slides and audio presentation. Posttest will reinforce information presented.

Learning Objectives
After participating in this activity participants will be able to:

    1. Recognize why we document
    2. Recognize challenges of documentation in the electronic environment
    3.  Perform optimal documentation
    4. Avoid risky documentation practices

Accreditation Statement

School of Medicine - CWRU

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Case Western Reserve University School of Medicine and Erica Remer, MD, Inc. Case Western Reserve University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Case Western Reserve University School of Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Planning Committee
Joan Zoltanski, MD, MBA, Activity Director
Chief Experience Officer
University Hospitals of Cleveland
Assistant Professor, Pediatrics
Case Western Reserve University School of Medicine
Dr. Zoltanski reports no financial relationship with a commercial interest relevant to this activity.

Erica E. Remer, MD, CCDS Co-Activity Director
President and Founder
Erica Remer, MD, Inc.
Dr. Remer reports no financial relationship with a commercial interest relevant to this activity.

Disclosure Statement
The policy of Case Western Reserve University School of Medicine CME Program (CWRU CME) requires that the Activity Director, planning committee members and all activity faculty (that is, anyone in a position to control the content of the educational activity) disclose to the activity participants all relevant financial relationships with commercial interests. Where disclosures have been made, conflicts of interest, real or apparent, must be resolved. Disclosure will be made to activity participants prior to the commencement of the activity. CWRU CME also requires that faculty make clinical recommendations based on the best available scientific evidence and that faculty identify any discussion of “off-label” or investigational use of pharmaceutical products or medical devices.

Instructions
To receive a statement of credit for up to 0.75 AMA PRA Category 1 Credit™ you must:

  1.  Review and reflect on the full content of the recorded session.
  2.  Successfully complete the posttest. A score of 100% is required for passage.
  3.  Complete the evaluation.
  4.  Claim your credit.

Your credits will be recorded by the CWRU CME Program and made a part of your cumulative transcript.

Estimated Time to Complete this Educational Activity
Including review of any resource material and completion of the post-test, this activity is expected to take 0.75 hour to complete.

Fee
The cost of this program is $189.

To contact the CME Provider: Email CWRU CME at medcme@case.edu

Resources
Kuhn T, Basch P, et. al., Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians, Ann Intern Med, 2015; 162:301-303.
https://annals.org/aim/fullarticle/2089368/clinical-documentation-21st-century-executive-summary-policy-position-paper-from

Remer EE, Advocating for Better Physician Documentation: Do No Harm, icd10monitor.com, April 23, 2018.
https://www.icd10monitor.com/advocating-for-better-physician-documentation-do-no-harm

Remer EE, How Voice Recognition Can Go Wrong, icd10monitor.com, July 15, 2019.
https://www.icd10monitor.com/how-voice-recognition-can-go-wrong

Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste, ECRI Institute, February 2016.
https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf

Evaluation and Management Services, Medicare Learning Network, CMS, August 2017 (check cms.gov for eventual pending updates).
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Stetson PD, Bakken S, et. al., Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9), Appl Clin Inform, 2012; 3(2):164-174.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3347480/

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