Medical Records and Documentation: Basic Information that May Be Critical - NASW

Medical records are critical in providing effective and comprehensive care for patients. This webinar will provide an overview of common claims involving Allied Healthcare Professionals and will discuss the 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 Healthcare 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.

Learning Objectives

On completion of this workshop, participants will be able to:

• Identify common claims involving Allied Healthcare Professionals as well as the standard of care.
• Explore medical records and types of documentation.
• Discuss record retention, release, and requests for information.
• Examine privacy and security issues impacting Allied Healthcare Professionals.

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:

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.

Important Notice

Because this webinar is on-demand, once you are registered and have created a login account, you can view the webinar at any time in whatever time increments are most convenient.

This online course is self-paced/non-interactive. Course questions can be directed to: contact@trustrms.com.

Having technical issues?

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

Continuing Education Credits

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.

This program is approved by the National Association of Social Workers (Approval #886836501-2341) for (1) continuing education contact hour for ethics.

Approval Date: 9/1/2023
Expiration Date: 9/30/2025

Trust Risk Management Services, Inc. Continuing Education Grievance Policy for NASW 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. TRMS will comply with all legal and ethical guidelines for non-discrimination in promotional activities, program content, and in the treatment of CE participants. 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 a live workshop, on-demand webinar, or the continuing education test, a TRMS representative will mediate and will be the final arbitrator. If the participant requests action, the CE Director or a TRMS representative 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 record-keeping purposes. The aggrieved individual does not need to sign the note. If the grievance specifically concerns TRMS, the CE Director or a TRMS representative will attempt to arbitrate.
• The timeframe for the grievance will be resolved within 30 days from the date of the complaint.

Direct correspondence to: 
Continuing Education
Trust Risk Management Services, Inc. (TRMS)
111 Rockville Pike, Suite 700
Rockville, MD 20850
Phone: (800) 477-1200
Email:  grievances@trustinsurance.com

Presenter

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