Course: Risk Management Essentials: Documentation
Author: Rosemary Gafner and James Schutte
AMA PRA Category 1 credits: 10
Estimated Hours to Complete Course: 9.00
Estimated Minutes to Complete Test: 60
Course Release Date: 3/1/2017
Course Expiration Date: 12/31/2021
A comprehensive examination of proper documentation practices.

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Risk Management Essentials: Documentation

The human and financial toll of poor documentation practices is staggering.  Every year, thousands of patients die or are injured by mistakes like the failure to leave legible medical instructions in the chart, specialty reports that are provided too late and are not brought to the attention of the attending physician, and indecipherable medication orders that resulted in the wrong drug or the wrong dosage being delivered. Physicians also suffer: poor documentation can result in denied claims for payment as well as discipline from state medical boards. This course is designed to help physicians avoid these issues.
Upon completion of this course,  youshould be able to:
1. Explain why poor documentation is a major factor in many “failure to diagnose” and other malpractice claims.
2. Avoid documentation issues that can lead to disciplinary action from CMS and state medical boards.
3. Apply the elements of the LAWSUIT documentation model to your own charts, and explain why each is important.
4. Use accepted abbreviations and symbols in your charting so that errors are avoided.
5. Handle documentation of test results and other reports so that patient safety is improved.
6. Avoid billing practices that will likely lead to problems with Medicare/Medicaid as well as private insurers.
7. Document informed consent in a defensible manner.
8. Identify and avoid common pitfalls in documentation that can lead to medical errors.

Target Audience
This course is designed for physicians who want comprehensive information on proper medical record documentation.

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 10 AMA PRA Category 1 creditsTM.

This course was developed by Rosemary Gafner, Ed.D. and James E. Schutte, Ph.D. Their CVs are available online 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 10 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: 10 hours.

This activity is valid for release March 1, 2019 and will expire December 31, 2021.

Commercial Support

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


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