Course: Risk Management Consult: Documentation, 2nd Edition
Author: Rosemary Gafner and James Schutte
AMA PRA Category 1 credits: 6
Estimated Hours to Complete Course: 5.50
Estimated Minutes to Complete Test: 30
Course Release Date: 9/1/2014
Course Expiration Date: 12/31/2021
The role of documentation and electronic health records in reducing liability.

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Risk Management Consult
Documentation, 2nd Edition


Electronic health records (EHRs) solve many of the problems associated with paper records: Because entries must be entered in print form and are automatically time-stamped, illegible handwriting, out-of-sequence notes, misplaced pages, and other common problems are no longer even possible. And the increased documentation required to submit claims using ICD-10 codes will make the medical record more complete and useful to the patient’s ongoing care.


Upon completion of this course, a physician should be able to:

1.  Explain why poor documentation is a major factor in many “failure to diagnose” and other malpractice claims.
2.  Use electronic media to communicate with patients in ways that do not place you at risk of HIPAA violations.
3.  Use accepted abbreviations and symbols in your charting so that errors are avoided.
4.  Understand the importance of encrypting EHRs, and how mobile devices can be used to access patient records without downloading them.
5.  Avoid billing practices that will likely lead to problems with Medicare/Medicaid as well as private insurers.

Target Audience
This course is designed for physicians of all specialties who want information on defensible documentation and the push to convert to electronic health records.


This is a self-study course consisting of text and CME test.  Physicians should read the course content, answer the test questions and submit the answers for scoring.  Those who complete the course with a score of 80 percent or higher will earn a maximum of 6 AMA PRA Category 1 creditsTM.


This course was developed by Rosemary Gafner, Ed.D. and James E. Schutte, Ph.D.  Their CVs are available at

CME Information

Medical Risk Management, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing education for physicians.  Medical Risk Management, Inc. designates this  enduring material  for a maximum of 6 AMA PRA Category 1 creditsTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.


Estimated time to complete this activity: 6 hours.

Commercial Support

This activity was developed solely by Medical Risk Management, Inc. without any commercial support.


Neither Dr. Gafner nor Dr. Schutte have anything to disclose.

Please check with your insurance carrier for approved courses before registering.  Courses not approved by your insurance carrier will not be accepted by them for any discounts they may offer.