Intensive Course in Medical Documentation: Clinical, Legal and Economic Implications for Healthcare Providers

Registration is now closed. Please consider our June or November 2024 course.

This is a longitudinal course which begins with a pre-assignment to select and submit actual medical record materials for expert review. Additionally, the participant will evaluate a provided sample medical record using a specially designed assessment tool. The onsite portion of the program consists of engaging lectures with relevant case presentations by experts; hands-on practice including discussion and analysis of the pre-assignment documents and demonstration of good documentation practices, including voice recognition technology; and a Q&A session where individual questions are addressed. The course culminates with small group sessions in which expert coding preceptors discuss improvement opportunities discovered in the submitted patient records provided by the attendees.

Post Course

The follow-up component includes a 3 and 6 month expert re-audit of post course patient records to provide ongoing feedback and maintenance of good documentation practices.

Thursday, March 7, 2024, 7:25 AM - Friday, March 8, 2024, 3:00 PM, VIRTUAL

1. Construct accurate, relevant, thorough and concise clinical documentation
2. Select the correct E/M codes for a service
3. Document patient encounters to support appropriate levels of service
4. Describe legal issues in documentation including standards of care, duty, confidentiality and health care fraud or abuse
5. Properly document controlled substance management
6. Identify risks and benefits of electronic medical record keeping, including template design and voice recognition technology

The registration fee for this course is $1600.

An administrative fee of $250 will be deducted from refunds for cancellations made within 14 days of the course.  All requests for refunds must be sent via email to [email protected].

Case Western Reserve University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™ (15.00 hours), Non-Physician Attendance (15.00 hours)

Mitigation of Relevant Financial Relationships

CWRU School of Medicine adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.