TeleSeminar Info

Educational Objectives: for Documentation

• 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.
• 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.