1. We teach you when to document, how much to document, and how to be accurate in your choice of words.
Clinicians don’t have time to waste on unnecessary documentation. They need to know what must be documented, and how to document concisely, adequately, and accurately. As specialists in legal medicine, our MD JD lecturers possess and can apply the full scope of a formal legal education and practical legal experience along with their medical practice experience. You will not be offered vague generalizations and impractical advice like “write everything” or “if it wasn’t written it wasn’t done.” These statements are misleading, reflect poor understanding of the laws of evidence, and show little experience with the actual use of medical records in legal proceedings. Our lecturers will correct many of the dangerous fallacies about record keeping that have plagued clinicians for generation after generation.
2. We show you what comments are inappropriate in documentation.
One wrong choice of words can make an otherwise defensible case indefensible. We will sensitize you to the types of comments that you should omit from the records.
3. We show you how medical records are used in evidence, and how proper documentation will protect you from legal problems.
As specialists in legal medicine, our lecturers deal extensively with the use of records as evidence in medical malpractice cases, licensing board actions, hospital disciplinary proceedings, and the use of your records as evidence in criminal and other areas of litigation. You will learn what common documentation errors repeatedly result in legal problems for clinicians. The usual record keeping presentations given by lecturers who lack backgrounds in both medicine and law do not teach you what to actually document in a wide range of legally hazardous situations. Our lectures will.
4. We address the law of medical record confidentiality including both HIPAA and the California Confidentiality of Medical Information Act.
Record confidentiality is a complex area that requires careful and legally correct instruction by lecturers who have an experience-based understanding of what is practical and impractical in a busy clinical practice. You will also learn what communications are privileged, and how to correctly respond to subpoenas and other actions commonly used to obtain protected patient information.