Understand the legal obligations and duties arising from the use and retention of medical records.
Many new clinical staff are required to navigate and document in the medical record. However, many staff do not have basic knowledge of the medical record, who can access, and who can document in the medical record. They also do not understand what is in a medical record, what is required, and how to best document in the medical record. This presentation will help those responsible for navigating and documenting in the medical record to understand those basic requirements. The live webinar will explain the basics of medical records, sources of records, and who can access and document in the medical record. The webinar will also identify basic documentation tips and types of medical records with examples.
Learning Objectives
- You will be able to define what a medical record is.
- You will be able to describe sources of medical records.
- You will be able to discuss who can access and document in medical records.
- You will be able to identity documentation tips.
Agenda
Medical Records Knowledge
- What Is a Medical Record?
- Are Medical Records Required?
- Why Are They Important?
Medical Records Overview
- Who Can Access Medical Records?
- Who May Document in the Medical Records?
- Sources of Medical Records?
Medical Records Sources
- Sources of Medical Records
- Pros and Cons
Maintenance of Records
- Maintenance of Records
- Retention of Medical Records
- What Happens If You Don’t Maintain?
Documentation Tips
- Basic Documentation Tips
- Corrections and Amendments to Records
Types of Records
- What Is Required?
- What Are the Standards?
- Examples
Speakers
Matthew Allen, MS, RN, CNS, PNP-BC,
Matthew Allen - Independent Legal Nurse Consultant- Legal Nurse Consultant in Henrietta, NY
- Clinical Nurse Specialist/Board Certified Pediatric Nurse Practitioner at University of Rochester Golisano Children’s Hospital in Rochester, NY
- Adjunct Clinical Professor at St. John Fisher University in Pittsford, NY
- Primary focus is on Pediatrics, Regulatory, and Policy Management at the Children’s Hospital, where he also evaluates whether nurses meet the legal definition of standard of care
- Frequently speaks within the hospital, as well as locally and nationally, on topics including medical records, medical-legal documentation, standards of care, quality improvement, and various disease-specific topics
- Coordinates, facilitates, develops/creates, and mentors/coaches/consults on policy, procedures, guidelines, and protocols to help ensure compliance with relevant practices based on policies, rules, and regulations
- Member of the following professional organizations: National Association of Pediatric Nurse Practitioners (NAPNAP); Sigma Theta Tau International, Epsilon Xi Nursing Society (STTI); American Association of Legal Nurse Consultants (AALNC)
- M.S. degree in PNP, University of Rochester School of Nursing; B.S. degree in nursing, St. John Fisher University
Who Should Attend
This live webinar is designed for medical records directors, health information directors, coders, business managers, office managers, nurses, hospital administrators, billing managers, social workers, counselors, release of records professionals, and compliance managers.
