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Product ID: 406580EAU
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Medical Record Charting Fundamentals

OnDemand Webinar (89 minutes)

Learn and understand basic medical record charting fundamentals and the impacts of HIPAA on medical chart access.During this topic we will cover the basics of medical charting, including defining the scope of medical charting, discussing the history and future of EMR, and covering the basic do's and don'ts of charting in both written and EMR format. We will cover charting best practices, including charting methods and tips and tricks designed to protect providers from lawsuits. We will consider the impacts of HIPAA on chart access and chart retention practices, as well as strategies to follow in the event of a violation. We will also discuss examples of how charting is used in litigation, preparing you for tactics used by plaintiff's attorneys in reviewing charting and exploiting gaps in charting.


Stuart Berman, Lowis & Gellen LLP Kelly Pachis, Lowis & Gellen LLP Patrick Viktora, Lowis & Gellen LLP


The Elements of a Medical Chart

• What Is a Medical Chart: Definitions

• What Is EMR?

• History of EMR


Best Practices of Medical Charting

• Joint Commission Requirements

• Basic Goals of Documentation

• Consideration of the Audience

• Gatekeeper Statutes

• How to See Documentation as a Defense

• Beyond the S-O-A-P Note

• Charting Do's and Don'ts

- Basics

- Who Can Add to the Chart

- How Do You Update or Correct the Chart?

- Documentation of Emerging Evaluations / Diagnoses

- EMR Prefills, Check Boxes and Cutting and Pasting

• Case Examples

- Uses in Deposition

Communication: Documentation of Contacts With Patient, Family, Staff and Colleagues

• Communication Matters

• How to Tell the Story

• Failure to Follow up by Doctor

• Documentation of Failures to Return for Care / Follow up by Patient

• Curbside Consultations

• New Forms of Communication

- Emails

- Text

- Voicemails and Private Cell Phones

- Integrated Portals

- Social Media

- Do's and Don'ts

How EMR Has Changed Medical Practice

• Notice

• Creation of Physician - Patient Relationship

• Issues

- Information Overload

- Issues With Dictation and Review

- Incompatible Systems

- Audit Trails

- GPS Data

- In Person Document Reviews

HIPAA Issues

• HIPAA Overview - What Is HIPAA?

• Impact of HIPAA: Lost Charts / Data Loss

• Impact of HIPAA: Provider Access

• How to Respond to a Known or Suspected Breach