ChiroClasses 105 Record Keeping Teleseminar.
“If you did not chart it, it was not done”. Time and time again we hear this, but are your patient’s health chart that complete? The medical record is second in importance only to the actual care of the patient. It is designed to remind you of the salient points of your patient’s case, but also to be used and often relied upon by other physicians who may be otherwise unfamiliar with your patient. Further the health record is used by third parties such as insurers to determine benefit qualifications, the legal system for things such as injury and disability claims, and by the government in eligibility for various state & federal programs such as medical assistance and social security disability. Your health record may also be used in civil and criminal cases as it constitutes a legal record of the patient’s health and whereabouts at a period in time. Your notes may be used as official documents in cases of malpractice, disability, boundary violation, and other legal disputes. This class will explain what should be documented in every patient encounter, and why. It will also review various forms of electronic medical records and discuss strengths and weaknesses of each form.
List the various governing bodies and organizations which may impose requirements on your record keeping of the patient’s health chart.
Describe various types of patient encounters and levels of documentation, and determine how to properly document each encounter.
Identify key components of the office entry forms and relate the importance of follow up and systems review.
Comprehend and explain ethical dilemmas which may arise in practice and identify ethical strategies to deal with them.
Compare and contrast various outcome assessment instruments, describe the importance of these tools and properly use and score various outcome assessment instruments.
Recite tests traditionally thought of as objective and tests traditionally thought of as subjective in the context of reliability and validity.
Define the characteristics of a good outcome assessment tool, and be able to properly implement it in clinical practice.
List the minimal record keeping requirements in the state or province in which you practice.
Compare and contrast the various types of electronic health records available.
Itemize the requirements of a “paperless” office.