Documentation: Strengthening the Patient Story, Part 2 - Clear Records
- Expiration Date
- Jul 27, 2025
- Media Format
- Interactive
- MOC Approved
- Yes
- Activity Type
- Online
- Est. Duration
- 0.25 hours
- Credits
-
CME/CNE: 0.25
$35
Target Audience
All physicians, nurses and other healthcare providers who document in electronic medical records.
- Documentation
Description
Medical records tell the story of patient care, thus contributing to patient safety. Some of the main attributes of good documentation—characteristics that maximize patients’ welfare while also reflecting healthcare professionals’ competent care—can be described through the framework of “five Cs”: Correct, Clear, Contemporaneous, Civil and Complete. Each of the “five C’s” will be discussed in this five-part series where we will further define documentation best practices and uncover strategies to enhance medical record keeping.
Learning Outcomes/Objectives
Upon completion, participants should be able to:
- Utilize strategies that result in clear documentation in patient medical records.
Copyright Information
Copyright © 2019-2022
CME Information
This activity is sponsored by LAMMICO/Medical Interactive.
LAMMICO/Medical Interactive designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Accreditation Statement
LAMMICO/Medical Interactive is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CNE Information
LAMMICO/Medical Interactive designates this enduring material for 0.25 contact hour(s). LAMMICO/Medical Interactive is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.
Learning Assessment
There will be a post test for this activity with a minimum performance requirement of 2 out of 3 correct answers.
Method and Medium
To obtain CME/CNE credit, view the entire online presentation, complete the evaluation and posttest and print your certificate online.
Resident Information
Residents will earn a certificate of completion.
State Requirements
This course may meet specific CME requirements for the following states. It is the user's responsibility to confirm whether content meets the user's state's specific requirements:
- Connecticut - This activity includes content in Risk Management
- Massachusetts - This activity includes content in Risk Management
- Pennsylvania - This activity includes content in Risk Management / Patient Safety
- Texas - This activity includes content in Ethics and/or Professional Responsibility
MOC Approval Statement
Through the American Board of Medical Specialties ("ABMS") ongoing commitment to increase access to practice relevant Maintenance of Certification ("MOC") Activities through the ABMS Continuing Certification Directory, Documentation: Strengthening the Patient Story, Part 2 - Clear Records has met the requirements as an MOC Part II CME Activity (apply toward general CME requirement) and/or an MOC Part II Learner Assessment Activity for the following ABMS Member Boards:
MOC Part II CME Activity
- American Board of Allergy and Immunology
- American Board of Family Medicine
- American Board of Medical Genetics and Genomics
- American Board of Nuclear Medicine
- American Board of Physical Medicine and Rehabilitation
- American Board of Plastic Surgery
- American Board of Preventive Medicine
- American Board of Psychiatry and Neurology
- American Board of Radiology
- American Board of Urology
- American Board of Colon and Rectal Surgery
ABIM
Successful completion of this CME activity enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC points.
ABIM MOC points can only be submitted if the participant provides his/her ABIM member number and date of birth to this provider.
ABP
Successful completion of this CME activity, which includes participation in the activity, with individual assessments of the participant and feedback to the participant, enables the participant to earn 0.25 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit.
ABP MOC points can only be submitted if the participant provides his/her ABP member number and date of birth to this provider.
ABA
Successful completion of this CME activity, which includes participation in the activity, with individual assessments of the participant and feedback to the participant, enables the participant to earn 0.25 MOC points in the American Board of Anesthesiology (ABA) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABA MOC credit.
ABA MOC points can only be submitted if the participant provides his/her ABA member number to this provider.
ABPath
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Pathology’s (ABPath) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABPath MOC credit.
ABPath MOC points can only be submitted if the participant provides his/her ABPath member number and date of birth to this provider.
ABOHNS
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to meet the expectations of the American Board of Otolaryngology’s Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of recognizing participation.
ABOHNS MOC points can only be submitted if the participant provides his/her ABOHNS member number and date of birth to this provider.
ABS
Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
ABS MOC points can only be submitted if the participant provides his/her ABS member number and date of birth to this provider.
ABTS
Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME requirements of the American Board of Thoracic Surgery’s Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABTS credit.
ABTS MOC points can only be submitted if the participant provides his/her member information as requested to this provider.
ABOS
Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME requirements of the American Board of Orthopaedic Surgery’s Maintenance of Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABOS credit.
ABOS MOC points can only be submitted if the participant provides his/her member information as requested to this provider.
Analyzing decades of medical malpractice claim data has led the MI faculty to narrow our focus to pinpoint the most important roots of patient safety issues across a host of medical specialties. When we boil down our collection of risk management education topics, these key concepts most keenly respond to the roots of patient safety issues:
Cognition
Error in the mental action or process of learning can lead to adverse events stemming from inaccurate or incomplete thinking, perceiving, experiencing, recognizing, remembering and judging. Courses marked with this designation indicate that information presented within that specific education activity will illuminate actionable ways to improve analysis and synthesis of information, diagnosis and clinical decision making.
Communication
Misunderstandings can lead to adverse events arising from errors in written, verbal and non-verbal information exchange. Courses marked with this designation indicate that concepts presented within that specific education activity will feature actionable ways to improve mutual understanding between healthcare providers and/or between medical professionals and their patients.
Performance
Reactive behavior resulting in inaccuracy, incompletion, expensive and untimely tasks can lead to adverse events arising from poor execution of an action and/or fulfillment of a request. Courses marked with this designation indicate that the specific education activity will present realistic ways to apply learning, implement changes in a medical practice, improve competencies, critically assess performance, and utilize and incorporate evidence-based best practices.
Professionalism
Breach of competency standards and ethical values can result in adverse events stemming from a misunderstanding of professional expectations. Courses marked with this designation indicate that the education activity will clarify professional expectations in an effort to improve advocacy and participation, provider wellness, ethical decisions, cultural competence, professional organization participation, and adherence to patient care guidelines.
System
System errors in medicine primarily consist of interrelated and interdependent components that habitually influence one another, and can often result in adverse consequences. Courses marked with this designation indicate that the education activity will present ways to address legal and regulatory issues, coordination of care and teamwork, electronic health record IT issues, policies and procedures, cost and risk benefits, and quality improvement activities.
Disclosure Policy
LAMMICO/Medical Interactive requires planners, speakers, faculty and all those who influence the content of a CME/CNE activity to disclose any financial relationships they have with ineligible companies that are relevant to the activity. The disclosures shall be reviewed for any conflict of interest and subject to a mechanism for resolution of conflict of interest. A disclosure statement of relevant financial relationships will be made to the audience prior to the activity.
Disclosure Statement
The authors, editors, reviewers and planning committee members for this activity have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Author(s)
Karen K. Davis, MA, CPHRM - Read Bio
Medical Expert Reviewer(s)
Karl N. Hanson, MD, FAAFP - Read Bio
Managing Editor(s)
Dawer Azizi, MHA, BSN, RN, CPHRM, LAMMICO Director of Risk Management
Sharon Cusanza, MSN, RN, NEA-BC, LAMMICO Senior Risk Management Education Specialist
Accredited Provider Program Director
Sharon Cusanza, MSN, RN, NEA-BC, LAMMICO Senior Risk Management Education Specialist
Content Advisors/Planning Committee Members
Dawer Azizi, MHA, BSN, RN, CPHRM, LAMMICO Director of Risk Management
Geri Cook, RHIA, CPHRM, LAMMICO Risk Management Manager
Sharon Cusanza, MSN, RN, NEA-BC, LAMMICO Senior Risk Management Education Specialist
Carol A. Curran, RNC, MS, OGNP, LAMMICO Senior Perinatal Educator and Medical Interactive Business Specialist
Karen K. Davis, MA, CPHRM, LAMMICO CME/CNE Writer/Editor
Amanda Martin-Sanchez, MEd, BSN, RN, CNOR, LAMMICO CME/CNE Educator
Lynda Sanders, LAMMICO Continuing Education Specialist
Karen Tong, Patient Representative and LAMMICO Communication Strategist
Joseph T. D. Tran, Associate General Counsel
Lynne Vega, RN, LAMMICO Hospital RM Specialist
Electronic Hardware and Software Requirements
To view our online presentations, your computer must meet the requirements below:
Hardware: Participants must have a personal computer with internet connection and speakers or an iOS or Android phone.
Operating System
Windows or Mac OS for desktop computers.
iOS or Android for mobile devices
Browser (Internet Explorer is NOT recommended as a browser for any MI courses since it is no longer supported by Microsoft)
Firefox 55 or above
Chrome 60 or above
Safari 11 or above
Microsoft Edge
Bandwidth
High Speed or DSL
Web Master Contact Information
For assistance, contact Shea Ivey at (866) 398-1038 or help@medicalinteractive.com