The following Documentation and Provider Standards Training educates healthcare providers on the significance of documentation compliance in healthcare. It also provides an introduction to all things related to healthcare compliance, which is important for all healthcare facilities to know about.
What you will learn:
- Standards for medical documentation
- Legal requirements in healthcare documentation
- How to accurately record patient information
- Common errors in healthcare documentation
- Professional conduct standards for healthcare providers
- How to establish consistent documentation practices
- How to handle sensitive information in healthcare
Details
Course length: 45 minutes
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 education to physicians. Our Continuing Medical Education (CME) program is committed to enhancing the knowledge, skills, and professional performance of healthcare providers to improve healthcare outcomes. Through high-quality educational activities, we aim to address the identified educational gaps 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.
Get Certified
American Medical Compliance (AMC) is a leader in the industry for compliance, Billing, and HR solutions. To become certified, please visit us at: American Medical Compliance (AMC).
Reach out for other courses by visiting the AMC Course Library.
Staying Compliant in Healthcare
HIPAA plays a large role in healthcare compliance. Additionally, the HIPAA Privacy Rule applies to health plans, healthcare clearinghouses, and healthcare providers who perform specific electronic healthcare transactions. It establishes national standards to protect individuals’ medical records and other individually identifiable health information, which is collectively defined as “protected health information.” The Rule imposes restrictions and limitations on the uses and disclosures of protected health information that may occur without a person’s consent. It also mandates the implementation of suitable safeguards to preserve the privacy of such information.
Documentation Guidelines and Standards
Furthermore, the legal system views documentation as a fundamental component. To further emphasize the risk management aspect, it is deemed a serious violation and departure from the standard of care in and of itself when pertinent data is not documented. Of course, there are many more reasons why clinical care documentation is necessary outside of avoiding legal risk. A patient’s record serves as the only permanent documentation of their care. This is because it changes over time and is a valuable source of information for emergency care, research, and quality control.
Provider Compliance and Responsibilities
Additionally, the federal government’s False Claims Act (FCA) of 1986 explicitly targeted fraud and abuse in the healthcare industry to eliminate it. The United States may bring triple damages lawsuits against violators of the FCA, in addition to $5,500–11,000 for each fraudulent claim. In 1993, the Attorney General declared that the Department of Justice would give high priority to tracking fraud and abuse to combat the growing prevalence of these crimes. The Health Care Fraud and Abuse Control Program (HCFAC) was formed in 1993 by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HCFAC received $248,459,000 from HHS and the Attorney General in 2007 to combat healthcare fraud and abuse.
The course provides further information regarding compliance, the legality behind documentation, etc. To learn more, click the button belo
