Noteworthy: The How, What, Where and Why of Medical Records
- : Online
Medical records are integral to good quality patient care. They enable continuity of care, reduce errors, and improve outcomes. This interactive session helps doctors and practice managers to create good quality medical records and deal with medical documentation issues such as release to third parties, secure storage of personal information, retention of records, and access to records when leaving a group practice. It covers how to avoid pitfalls of electronic record keeping. The activity uses case scenarios and quiz questions. Take home information is supplied. The session focusses on areas identified as being problematic for doctors in recent court and medical board findings, the medical literature, feedback at education activities, and a medical indemnity insurer’s advice requests and claims and complaints experience.
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By the end of theNoteworthy: the How, What, Where and Why of Medical Documentation session, participants should be able to:
- employ the mnemonic “SOAP” to create logical and appropriately-detailed clinical notes
- explain the medico-legal requirements around when and how to release information in medical records to others
- recognise common problems with medical records that can adversely affect patient care and medico-legal outcomes
- appropriately manage unsolicited information provided about a patient by a third party.
There is no formal assessment. Participants complete an evaluation form at the end of the activity.