The Mastering Healthcare Documentation Training teaches healthcare providers how to create comprehensive, accurate medical records that enhance patient care, ensure legal compliance, and drive quality improvement. Additionally, participants will learn essential documentation elements, effective techniques for writing clear and objective medical notes, and how to navigate electronic health record (EHR) systems. Proper documentation improves communication, reduces legal risks, and supports seamless patient care, making this training essential for maintaining high standards in healthcare.
What You Will Learn:
- Essential elements of comprehensive healthcare records
- Techniques for writing clear, concise, and objective medical notes that accurately reflect patient care
- The functionality of electronic health record (EHR) systems used in healthcare settings
Details:
Course length: 45 minutes; CME: 0.75
Languages: American English
Key features: Audio narration, learning activity, and post-assessment.
American Medical Compliance is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education to physicians. Our Continuing Medical Education (CME) program is committed to enhancing the knowledge, skills, and professional performance of healthcare providers to improve patient care outcomes. Through high-quality educational activities, we aim to address the identified educational gaps and to support the continuous professional development of our medical community. American Medical Compliance designates this activity for a maximum of 0.75 AMA PRA Category 1 Credits. Physicians should only claim this credit for their complete participation in this activity.
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Introduction to Healthcare Documentation
The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.
This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. Also, it provides a cognitive framework for clinical reasoning.
The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them.
Overall, this course teaches healthcare providers to use the SOAP note format for structured, organized documentation. Mastering this method enhances clinical reasoning, ensuring accurate assessment, diagnosis, and treatment. Additionally, the SOAP note helps clinicians evaluate patient information systematically while maintaining clear, consistent records. Applying this framework improves communication, supports legal compliance, and enhances patient care.
Electronic Health Records (EHRs)
An Electronic Health Record (EHR) is an electronic version of a patients medical history, that is maintained by the provider over time. It may include all of the key administrative clinical data relevant to that persons care under a particular provider. This includes demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.
The EHR automates access to information and has the potential to streamline the clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces. This can include evidence-based decision support, quality management, and outcomes reporting.
EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.
For example, the EHR can improve patient care by:
- Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
- Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
- Reducing medical error by improving the accuracy and clarity of medical records.
In sum, this course teaches healthcare providers to use Electronic Health Records (EHRs) to improve care, streamline workflows, and enhance decision-making. Providers will learn to store and organize key patient data, reduce errors, prevent duplicate tests, and ensure quick access to information. Mastering EHRs improves accuracy, communication, and efficiency in patient care.
Benefits and Drawbacks of Electronic Health Record Systems
Over the past decade, virtually every major industry invested heavily in computerization. Yet, despite these advances in our society, the majority of patients are given handwritten medication prescriptions. Similarly, very few patients are able to schedule an appointment to see a provider without speaking to a live receptionist.
Electronic health record (EHR) systems have the potential to transform the health care system.
Researchers have examined the benefits of EHRs by considering clinical, organizational, and societal outcomes. Clinical outcomes include improvements in the quality of care, a reduction in medical errors, and other improvements in patient-level measures that describe the appropriateness of care.
On the other hand, organizational outcomes have included such items as financial and operational performance, as well as satisfaction among patients and clinicians who use EHRs. Lastly, societal outcomes include being better able to conduct research and achieving improved population health.
Overall, this course teaches healthcare providers how Electronic Health Records (EHRs) can modernize patient care by replacing paper-based processes with digital efficiency. Providers will learn how EHRs improve access to medical records, streamline workflows, and enhance communication. Mastering EHR systems allows for safer, faster, and more accurate care, reducing errors and improving patient outcomes.
Why We Need Electronic Health Records
EHR systems can include many potential capabilities, but three particular functionalities hold great promise in improving the quality of care and reducing costs at the health care system level:
- Clinical decision support (CDS) tools
- Computerized physician order entry (CPOE) systems and
- Health information exchange (HIE).
These and other EHR capabilities are requirements of the “meaningful use” criteria set forth in the HITECH Act of 2009.
A CDS system is one that assists the provider in making decisions with regard to patient care. Some functionalities of a CDS system include providing the latest information about a drug. Also, it includes cross-referencing a patient allergy to a medication. A CDS system can also alert for drug interactions and other potential patient issues that are flagged by the computer. With the continuous growth of medical knowledge, each of these functionalities provides a means for care to be delivered in a much safer and more efficient manner. As more and more CDS systems are used, one can expect certain medical errors to be averted and that, overall, the patient will receive more efficient and safe.
In sum, this course teaches healthcare providers how EHR tools improve care and reduce costs. Providers will learn how Clinical Decision Support (CDS), Computerized Physician Order Entry (CPOE), and Health Information Exchange (HIE) enhance safety and efficiency. CDS flags drug interactions, allergies, and risks, preventing errors and improving outcomes. Mastering these tools helps providers meet “meaningful use” standards and deliver better care.
