Medical Record Keeping



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Continuing Medical Education Program INTENSIVE COURSE IN Medical Record Keeping with Individual Preceptorships May 8-9, 2014 November 6-7, 2014 Hilton Cleveland East Beachwood Beachwood, Ohio

Intensive Course in Medical Record Keeping with Individual Preceptorships Who Should Attend? The Intensive Course in Medical Record Keeping is designed for physicians in all specialties who need or wish to increase their ability to effectively maintain medical records. Medical Record Keeping Statement of Need The need for maintaining complete and accurate patient records has never been more crucial than in today s fast-paced environment. Appropriate record keeping involves not just good medical practice, but also a keen awareness and appreciation of regulatory guidelines, billing issues and legal constraints. The Intensive Course in Medical Record Keeping is designed for physicians in all specialties who want or need to keep abreast of current concepts and requirements for proper documentation of patient diagnosis, treatment, and follow-up activity. This course has been designed to assist the practitioner as he or she applies key record keeping principles to enhance quality care and meet compliance standards. Participant Learning Objectives After attending this course, participants will be able to: State the essential items needed in every medical record Properly document medication prescribing and dispensing in an office setting Describe the necessity for accuracy and completeness in office records Construct an office note after a patient visit which could assist a colleague in caring for that patient Discuss the use of E & M code for office visits based on HCFA rules Identify several of the risks and benefits of electronic record keeping Educational Design and Methodology This is a longitudinal course which begins with a pre-assignment of medical record review. The onsite portion of the program will include lectures, case presentations, progress note practice and a precepted chart review session (looking at records/charts you will submit at the start of the program). The post course components include a three and six month self critique of medical records followed by an expert preceptor review and feedback.

A g e n d a Thursday 7:30-8:00 am Registration 8:00-8:15 am Welcome and ARS Pre-Test erica Remer, MD, FACEP 8:15-8:45 am Documentation of the Clinical Encounter erica Remer, MD, FACEP 8:45-9:30 am The Coder s Approach to the Medical Record- ask her for her alphabet soup! Colleen Deighan, RHIT, CCS 9:30-10:30 am Legal Requirements for Medical Record Keeping shannon Jerse, JD 10:30-10:40 am Break 10:40-11:45 am Physician Compliance Issues shannon Jerse, JD 11:45-12:15 pm Lunch 12:15-1:15 pm E & M Coding: Keeping it Simple, Getting it Right sally Streiber, BS, MBA, CPC, CEMC 1:15-3:00 pm Clinical Decisions and Documentation when Prescribing Controlled Drugs theodore Parran, MD 3:00-5:00 pm Don t Invite the Feds to Your Office John Irwin, JD, MD 5:00 pm Adjourn Friday 7:30-8:00 am Registration 8:00-8:45 am EMR Is Here To Stay: How to Live With It Erica Remer, MD, FACEP 8:45-9:15 am ICD 10 and You sandy Seabold, RHIA, MBA 9:15-10:00 am Let s Practice Good Documentation Part 1 erica Remer, MD, FACEP and John Irwin, JD, MD 10:00-10:10 am Break 10:10-11:45 am Let s Practice Good Documentation Part 2 erica Remer, MD, FACEP and John Irwin, JD, MD 11:45-12:15 pm Lunch 12:15-12:50 pm The Expert Panel Answers Your Questions Moderator - Erica Remer, MD, FACEP Panel - Colleen Deighan, RHIT, CCS; John Irwin, JD, MD; Sally Streiber, BS, MBA, CPC, CEMC 12:50-1:00 pm ARS Post-Test 1:00-3:00 pm Group Review and Discuss Submitted Records 3:00 pm Adjourn

f a c u l t y Co-Director Erica Remer, MD, FACEP Clinical Instructor of Emergency Medicine Case Western Reserve University School of Medicine Physician Clinical Documentation Education Coordinator University Hospitals Case Medical Center Co-Director Theodore V. Parran, Jr., MD Carter and Isabel Wong Professor of Medical Education Medical Director, CME Case Western Reserve University School of Medicine John R. Irwin, JD, MD, FCLM Attorney at Law Colleen Deighan RHIT, CCS, Senior Program Director, ICD-10 Implementation Cleveland Clinic Shannon Jerse, JD General Counsel St. Vincent Charity Hospital Deputy General Counsel Sisters of Charity Health System Sandy Seabold, RHIA, MBA Business Consultant Sally Streiber, BS, MBA, CPC, CEMC Manager, Coding Compliance and Education Department of Compliance and Ethics University Hospitals of Cleveland A team of medical records experts The policy of Case Western Reserve University School of Medicine CME Program requires that the Activity Director, planning committee members and all activity faculty (that is, anyone in a position to control the content of the educational activity) disclose to the activity participants all relevant financial relationships with commercial interests. Disclosure will be made to activity participants prior to the commencement of the activity. Case Western Reserve University School of Medicine also requires that faculty make clinical recommendations based on the best available scientific evidence and that faculty identify any discussion of off-label or investigational use of pharmaceutical products or medical devices. Accreditation Case Western Reserve University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Case Western Reserve University School of Medicine designates this live activity for a maximum of 14.5 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Location and Hotel Accommodations The course will be held at the Double Tree by Hilton Cleveland East Beachwood, 3663 Park East Drive, Beachwood, Ohio, at the Chagrin Boulevard exit off of I-271. Call the Double Tree by Hilton directly at 216-464-5950 or 877-865-5824 to make your reservations. A block of rooms has been reserved. Medical Records is the group name. For More Information Call Case Western Reserve University, Continuing Medical Education Program, phone (216) 983-1239 or (800) 274-8263 or visit http://casemed.case.edu/cme/. Disclaimer: The information and material provided in this course is intended solely for educational purposes. When actual medical records are reviewed, reviewers provide suggestions and guidelines only. Since rules vary from state to state, it is impossible to address specific issues. Therefore, feedback should not be relied upon for licensure or professional liability purposes. Practitioners should rely on their own professional judgment. Any specific questions should be referred to your own state and legal authorities.

r e g i s t r a t i o n Registration Information The registration fee for this course is $1050. Fees include tuition, educational materials, breakfast, lunch and breaks. An administrative fee of $125 will be deducted from fees for cancellations made after April 24 (for May course) or October 23 (for November course). All requests for refunds must be made in writing. Four Ways to Register 1. Register online at http://casemed.case.edu/cme/. 2. Mail this completed form with a check payable to Case Western Reserve University for $1050 or complete the credit card information and send to: Continuing Medical Education Program 10524 Euclid Avenue Cleveland, Ohio 44106-6026 3. Fax this form with your credit card number to (216) 844-8133 4. Phone (216) 983-1239 or (800) 274-8263 with the information requested below and your credit card number. Registration Form May 8-9, 2014 CID #2472 November 6-7, 2014 CID #2473 Medical Record Keeping with Individual Preceptorships Name Degree Specialty Address City State Zip SSN (last 4 digits) E-mail Phone Fax Make checks payable for $1050 to: Case Western Reserve University or complete credit card information. l MasterCard l Visa l Discover Credit card # Card expiration date Signature Date l Dietary restrictions? l I will need parking Happenings in Cleveland Cleveland Orchestra Ticket information (216) 231-1111 Cleveland Museum of Art Information (216) 421-7340 Playhouse Square Center Ticket information (216) 771-8403 Cleveland Play House Ticket information (216) 400-7000 Rock and Roll Hall of Fame and Museum Information (888) 764-7625 Great Lakes Science Center Information (216) 694-2000 Or for more Cleveland activities visit Positively Cleveland at http://www.positivelycleveland.com