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ForwardDocumentation: The Next Level with Cara H. Staus, CPHRM, FASHRM
Documentation is the foundation for communication for patient care, is one of the basic risk management tools, and reflects professionalism and the credibility of the psychiatrist. It is also one of the most rushed or overlooked “required tasks.” Documentation is vital to the defense of a licensing complaint or malpractice allegation, and it is imperative that providers practice defensible documentation to reduce their legal exposure, evidence the standard of care and compliance with regulations as well as support good quality of care. This webinar reviews basic documentation principles, whether notes are written on paper or in an electronic health record, explains the importance of the medical record as a legal document, offers examples of good documentation vs. vulnerable documentation and addresses special situations to ensure that documentation is objective, timely, succinct and complete to maximize defensibility of a potential claim or board action.
Target Audience
______ Introductory __X____ Intermediate ______ Advanced
Learning Objectives
Explain the fundamental role of documentation to support patient care and clinical decision making
Identify best practices for effective documentation by offering guidelines and examples
Explore documentation standards and regulatory requirements
Analyze the impact of documentation on liability and address common obstacles to mitigate risk
As an Assistant Vice President of the Risk Management Group, Cara provides risk management consulting services to Allied World’s medical professional liability policyholders and insured psychiatrists, psychologists, psychiatric nurse practitioners and physician assistants. She works directly with policyholders to develop individualized action plans to mitigate potential loss based on their unique exposures and risk management needs. Additionally, Cara assists these clients with ongoing medical educational programs as well as policy and procedure review and development. Cara has over 20 years of experience working in healthcare, specifically in the areas of risk, patient safety insurance, claims, captive management, health information management and business operations. Throughout Cara’s career she has been a strategic leader in the areas of risk mitigation, process improvement and claim management. Cara’s experience has been primarily in the senior living industry inclusive of long-term care, home health, hospice, outpatient, behavioral health, assisted and residential living. Cara is an active member of the Connecticut Society for Healthcare Risk Management (CSHRM) and is currently serving as President. Cara is a member of the American Society for Healthcare Risk Management (ASHRM), and serves as the Chair of Board of Commissioners for the Berlin Visiting Nurses Association, Berlin, Ct. Cara earned her B.S. degree in Management from Keene State College. Cara is a Certified Professional in Healthcare Risk Management (CPRHM) and has achieved the designation Fellow of the American Society for Healthcare Risk Management (FASHRM).
Austen Riggs Center Inc. adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Medical Education. All those at Austen Riggs Center involved in the planning of this activity, including the presenter(s) listed above, report they have no relevant financial relationships with an ineligible company*.
The views and opinions expressed in this presentation are those of the presenter(s) and do not necessarily represent the official policy or position of the Austen Riggs Center.
* An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
As a Jointly Accredited Organization, The Austen Riggs Center, Inc. designates this learning activity AMA PRA Credit™ risk management study.
Available Credit
- 1.50 AMA PRA Category 1 Credit™
ACCME - As a Jointly Accredited Organization, The Austen Riggs Center, Inc. designates this learning activity for a maximum of 1.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 1.50 APA
As a Jointly Accredited Organization, The Austen Riggs Center, Inc. designates this learning activity for 1.50 continuing education credit(s) (CE) for psychology. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.
Austen Riggs Center, Inc. is recognized by the New York State Education Department’s State Board for Psychology as an approved provider of continuing education for licensed psychologists #PSY-0115.
- 1.50 ASWB-ACE
As a Jointly Accredited Organization, The Austen Riggs Center, Inc is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organization, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Austen Riggs Center maintains responsibility for this. Social workers completing this will receive 1.50 continuing education credit(s).Austen Riggs Center, Inc is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0843.
- 1.50 Contact Hours/ ParticipationA certificate of attendance for all Learners.