Medical Record Keeping

Medical Record Keeping Course Overview:

This Medical Record Keeping Course is designed for clinicians who would like to improve their medical record keeping skills. Attendees will learn best practices that will ensure that their medical records meet risk management standards, laws and regulations applicable to medical documentation. These skills will help improve medical care and enable more accurate communications between care providers. This intensive two day long course is critical for clinicians who have been found deficient in medical documentation either by hospitals or by regulatory agencies and has been approved by the California Medical Board as meeting the coursework requirements of physician probation.

Up to 19 CME Hours (17 CME Hours in Lecture; 2 CME Hours for the Pre-course) – 2 Day Program

For completion of this course, medical record workshops with analysis of submitted patient records are required. Get more information on submission of records.


Courses are held in the San Francisco Bay Area, typically nearby the San Francisco International Airport or within downtown San Francisco, depending on the number of registrants. Call for details and for help booking nearby hotels.

Program Content:

  1. Purposes of patient record documentation.
  2. Documentation and the law of evidence.
  3. Deficient records.
  4. Content of the patient records, including support of diagnosis and treatment plans.
  5. Other information that should be documented.
  6. Technical issues in documentation.
  7. Electronic health records.
  8. Documenting discussions with patient and/or family; including warnings, consent, informed consent and patient education.
  9. Records that show fulfillment of legal obligations, including review of prior and concurrent care records.
  10. Record keeping errors that increase liability risk
  11. Documentation in situations requiring increased caution, including patient non-compliance.
  12. Documenting frequently litigated conditions.
  13. Undermining the credibility of the records.
  14. Undermining the credibility of the record keeper.
  15. Maximizing reimbursement while minimizing risk of fraud and abuse accusations.
  16. Medical record confidentiality.
  17. Confidentiality when contacting the patient.
  18. Release of medical records with authorization.
  19. Release of medical records without authorization.
  20. Patients’ access to their own records.
  21. Medical record workshops with analysis of records.


$1249. Organizations sponsoring multiple registrants should call (650) 212-4904 to discuss reduced tuition fees that may apply.

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CME Accreditation:


At the conclusion of the course, attendees should be able to:

1.   Apply medical record keeping skills which will improve patient safety and continuity of patient care.

2.   Integrate satisfaction of patients and their families with health care by improving the quality of their medical records.

3.   Recognize and protect patients’ legal rights relating to their medical records.

4.   Recognize and comply with physicians’ legal responsibilities relating to documentation and information disclosure.

5.   Integrate cooperation among members of the health care team.

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the join provider-ship of the University of California, Irvine School of Medicine and the Western Institute of Legal Medicine. The University of California, Irvine School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

The University of California, Irvine School of Medicine designates this live and enduring materials activity for a maximum of 19 AMA PRA Category 1 Credits.  Physicians should claim only credit commensurate with the extent of their participation in the activity.

The University of California, Irvine School of Medicine Continuing Medical Education Department has reviewed this activity’s speaker and planner disclosures and resolved all identified conflicts of interest, if applicable.

General Disclaimer

The statements and opinions contained in this program are solely those of the individual authors and contributors and not of the WILM Programs. The appearance of the advertisements is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The content of this presentation and publication may contain discussion of off-label uses of some of the agents mentioned. Please consult the prescribing information for full disclosure of approved uses. The WILM Programs disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the presentation or advertisements.