Clinical Record Making: Essentials for Risk Management
Edward Zuckerman, Ph.D.
3.0 CE Hours Available
All orders include the entire presentation with handouts and a CE test.
Streaming videos and audio downloads will be available immediately after checkout
Mailed CD and DVD formats include the printed handouts and CE test in an attractive portfolio
Description
This seminar will provide you with specific information and working tools for creating clinical records. The seminar handouts will include sample forms and other resources.
Objectives
This seminar will provide you with specific information and working tools for creating clinical records. The seminar handouts will include sample forms and other resources. This seminar will enable you to describe:
- Ways to introduce new patients to your practice?s procedures
- Five methods of assuring fully informed consent
- What to record and not record
- How to ensure your documenting is HIPAA-compliant
Topics
Welcome to my practice
- What risk management means - Record retention and disposal - HIPPA: Gap analysis and safeguards decisions - Intake data collection - Sending a pre-appointment package
Documenting Informed Consent
- Five methods for assuring fully informed consent - The nature of consent - Voluntariness and competence - Issues with children and families - HIPAA-required complaint form - Informed consent to managed care
Documenting Decisions and Treatment
- What to record and not record - Quality records protect you
- Formats for Routine Progress Notes - HIPAA?s rules as a baseline -Notice of Privacy Practices and the ?Consent? -Client access to and amendment of your records - Diagnostic options - Termination documents