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Documentation Essentials: Patient Health Records and Other Clinical Systems

  • Business of Otolaryngology
  • General Lecture

Friday, November 11, 2022

1:00 PM - 2:30 PM

The Boca Raton Estate 1-2

Session Description

Medical documentation needs to be reviewed regularly with teams to help them stay on top of basic processes, in addition to provide understanding around updated guidelines. As an example, Informed consent to medical treatment is fundamental in both ethics and law. Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care. Successful communication in the patient-physician relationship fosters trust and supports shared decision making and reduces medical errors. This session will cover documentation, common error case examples, provide tools for risk assessment and give insight to help attendees identify gaps in their current processes.

Session Objectives

At the conclusion of this activity, the participants will be able to: • Reinforce documentation function and benefits • Recognize common documentation errors • Utilize provided tools to conduct a proactive risk assessment on current processes • Understand how to use resources to implement or enhance process for identified gaps