Medical Records and Documentation: Basic Information that May Be Critical - ASWB Credit ONLY

This 1 credit webinar was developed in 2020 for social work professionals. The webinar will familiarize professionals with strategies and techniques to reach outcomes quickly, effectively, and demonstrably, providing a rationale and theory supporting ethical therapy and by incorporating information and strategies to reduce risk.

Medical Records and Documentation: Basic Information That May Be Critical, Course #4535, is approved by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program to be offered by Trust Risk Management Services as an individual course. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE course approval period: 11/30/2022 - 11/30/2024. Social workers completing this course receive 1 Ethics continuing education credit.

Recorded video-based online activity.

Level: Beginner

LEARNING OBJECTIVES:

• Identify common claims involving Allied Health Professionals as well as the standard of care
• Describe ways to explore medical records and types of documentation
• Discuss record retention, release and requests for information
• Examine privacy and security issues impacting Allied Health Professionals

WEBINAR DESCRIPTION:
Medical records are critical in providing effective and comprehensive care for patients. This webinar will provide an overview of common claims involving Allied Health Professionals and will discuss general standard of care issues. The presenter will identify why medical records are important and what may/may not need to be documented. The presenter will explore types of medical records including written and electronic health records. She will discuss record retention, record release, and requests for information from individuals including third parties and family members. The presenter will explore privacy and security issues impacting Allied Health Professionals. HIPAA will be discussed as well as the applicability and importance of Business Associate Agreements.  She will explore protections as well as limitations regarding psychotherapy notes. In addition, the presenter will discuss the importance of providing and documenting informed consent and termination.  A case example will be explored to highlight the importance of documentation.

Target audience:  Social Workers in settings that provide: 

• Behavioral Health 
• Health Care      
• Addictions Treatment   
• Community Services /Resource Development    

Who serve in the role(s) of: 

• Case Management
• Counseling/Therapy 
• Supervision/Admin.  

 
With populations that include: 

• Children/Youth/Families  
• Aging   
• End-of-Life Issues/Grief & Loss   
• Victim or Protective Services  
• Physical/Intellectual Challenges

Agenda:

60 minutes — Post-test separate.

Legal Issues 

• Common Claims
• What Do the Courts Look At
• Standard of Care

The Medical Record 

• Importance of Policies Regarding Documentation
• Importance of Documentation
• What May/May Not Need to be Documented
• Electronic Medical Record/Written Record
• Documentation of Patient’s Compliance/Non-Compliance with 
• Treatment

Record Retention/Request for Records 

• Retention
• Patient Record Request
• Case Example
• Family Member Request
• Third Party Request

Addendums/Corrections 

Privacy and Security 

• HIPAA/State Privacy Requirements
• Psychotherapy Notes

Documentation via Electronic Means 

• Via Mobile Devices
• Via Text
• Via Email

Documenting Informed Consent 

• Minors, Incapacitated Persons
• Termination

Storing, Examining, Destruction of Records 

Begin earning CE credits now! 

• Get details and objectives, select a webinar, register, and create an account.
• View the webinar at your convenience (in whatever time increments are convenient).
• Pass an online exam and complete a brief online webinar evaluation.
• Download and print or save your CE certificate.

You are required to achieve a passing score of 80% or higher. 

Having technical issues?

Please contact TRMS at contact@trustrms.com. For questions, concerns, or to request special accommodations, please call 800-477-1200.

Trust Risk Management Services, Inc. Continuing Education Grievance Policy for ASWB Courses
Trust Risk Management Services, Inc. (TRMS) is fully committed to conducting all activities in strict conformance with the National Association of Social Workers, Code of Ethics.  TRMS will comply with all legal and ethical guidelines for non-discrimination in promotional activities, program content, and in the treatment of CE participants. In collaboration with the Social Work Planner, the TRMS CE Director is responsible for complying with these standards. While TRMS strives to assure fair treatment for all participants and to anticipate problems before they occur, occasionally grievances may be filed. In cases where a participant files a written or oral grievance, the following actions are taken:

• If the grievance concerns the content of an on-demand webinar or the continuing education test, approved for social workers only, the Social Worker Planner will mediate and will be the final arbitrator. If the participant requests action, the Social Worker Planner, in collaboration with the TRMS CE Director, will either provide a credit for a subsequent CE offering, or provide a partial or full refund of the CE fee already paid.
• Actions involving a credit or a refund will require a written note documenting the grievance for recordkeeping purposes. The aggrieved individual does not need to sign the note. If the grievance specifically concerns TRMS, the Social Worker Planner and the TRMS CE Director will attempt to arbitrate.
• The timeframe for the grievance will be resolved within 30 days from the date of the complaint.

Direct Correspondence For Grievances:
Brenda Ingram, Ed.D., M.S.W., L.C.S.W.; Social Worker Planner
Karen Greene, Director of Continuing Education 
Trust Risk Management Services
111 Rockville Pike, Suite 700
Rockville, Maryland 20850
(800) 477-1200
Email: grievances@trustinsurance.com

Presenter

Kristen Lambert, J.D., MSW, LICSW, CPHRM, FASHRM