Effective Documentation for Inpatient Services

1 CME Credit

1 CE Credit

ABQAURP sub-specialty credits: Managed Care 1.0, Patient Safety/Risk Management 1.0, Case Management 1.0, Transitions of Care 1.0, Physician Advisor 1.0


The prevalence of poor documentation in the medical record is dramatic. In fiscal year 2013, the improper payment rate in the Medicare Fee-For-Service program was 10.1%, representing 36 billion dollars in improper payments.  In all categories of services, the vast majority of the improper payments were related to insufficient documentation or in some cases no documentation of the care provided. These statistics highlight the fact that, though much attention has been turned to improved clinical documentation in recent years, much more work remains to be done in helping healthcare providers properly document the care they provide.

Documentation is important in helping to reduce the risk of successful malpractice claims, as well as, in effectively communicating with other healthcare providers.  High quality documentation can, therefore, be considered a patient safety issue as well as a financial and medicolegal concern.

The overarching goal of this course is to provide its audience with an overview of requirements for proper medical record documentation, discuss strategies being implemented, identify specific tools and actions that have shown promise, and highlight best practices that have been effective..

At the conclusion of the activity, attendees will be able to:
  • Apply proper documentation guidelines in order to decrease improper payments
  • Improve communication between healthcare providers related to improper documentation in the medical record
  • Utilize high quality medical record documentation in order to help mitigate malpractice litigation risk
  • Choose correct method in handling amendments, corrections, and delayed entries in the medical record
This course is intended for Physicians of all specialties, Nurses, and Other Health Care Professionals with appropriate CME credit and nursing contact hours offered for each profession.

The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

ABQAURP designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Creditâ„¢. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hour through the Florida Board of Nursing, Provider # 50-94.

This program is approved for Category 2 credit by the American Osteopathic Association.

All participants must achieve a final assessment score of at least seventy percent (70%) for recertification and continuing education credits. You have 60 days to complete the course after ordering. Please note: Exam candidates taking the Core Body of Knowledge and Diplomates renewing their certification may have less time to complete, as determined by deadlines imposed. This activity is valid from July 20, 2015 through March 15, 2018.

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COURSE FEES: Diplomate $29.00      Member $34.00      Non-Member $42.00


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About The Authors
Members of the CME Committee, Planners, and Faculty have disclosed to ABQAURP any relevant financial relationships. No relevant financial relationships or conflicts of interest exist in regard to the content of this activity.

Timothy J. Garrett, MD, MBA, FACHE, CHCQM

Dr. Timothy Garrett is Medical Director, Claims Review Specialist at Connolly/iHealth Technologies. Dr. Garrett's experience includes proven leadership in the hospital, healthcare, DRG review, and medical necessity review industries.
He is a Fellow of the American College of Healthcare Executives (FACHE), Fellow of the American College of Emergency Physicians (FACEP), Diplomate of the American Board of Emergency Medicine, and a published writer. He is an ABQAURP Diplomate, HCQM certified in 2012. Dr. Garrett specializes in: medical necessity reviews, DRG audits, Medicare compliance, leadership of teams, expert management of remote professionals, and client management.



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