Practical Tips to Avoid Legal Liabilities Associated with Medical Records

How to use tools to improve clinical documentation to avoid any legal liabilities associated with medical privacy.

Many providers are generally aware of the benefits associated with good clinical documentation, but they are worried about employing tools to encourage physicians to exercise better recording habits and to promote accuracy. Using "Clinical Documentation Specialists" or "Scribes" is more common than it was 5 years ago, but compliance concerns remain and must be understood. Healthcare organizations struggle to define and compile record sets, especially now that the type of media on which information is recorded and the use of EHRs are expanding. Multiple privacy laws applicable to medical records complicate the production of medical records. This topic will provide information to providers, executives, and HIM professionals to help them navigate the compliance issues associated with using tools that promote better documentation and to prepare for challenges. Participants will also hear about how to tailor record sets appropriately and to their best advantage, and how to deal with concerns under various regulatory schemes. Understanding these issues is critical to enhancing effectiveness, passing audits with flying colors, and ultimately, increasing revenues.