Medical Documentation: Clinical, Legal and Economic Implications for Healthcare Providers


Feb 28 - March 1
Medical Documentation

June 13-14
Medical Documentation

Who Should Attend?

This course is designed for physicians in all specialties, physician assistants and nurse practitioners who need or wish to improve their documentation skills, with particular regard to clinical communication, legal risk, regulatory compliance, and appropriateness for reimbursement.

Statement of Need

Medical education notoriously gives inadequate attention to teaching physicians how to properly document the patient encounter. Current challenges in maintaining accurate and complete patient records include the conversion to electronic medical records, ever-changing regulatory and billing guidelines, and legal constraints. This course aims to give providers the knowledge base and skills to generate compliant, risk-reducing, and reimbursable documentation.

Learning Objectives

After attending this course, participants will be able to:

  • Construct accurate, relevant, thorough and concise clinical documentation
  • Select the correct E/M codes for a service
  • Document patient encounters to support appropriate levels of service
  • Describe legal issues in documentation including standards of care, duty, confidentiality and health care fraud or abuse
  • Properly document controlled substance management
  • Identify risks and benefits of electronic medical record keeping, including template design and voice recognition technology


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 15.50 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

How to Register

  1. Register online by selecting from our calendar of courses.
  2. Mail the 2019 Documentation form with a check payable to Case Western Reserve University or complete the credit card information and send to:
    Continuing Medical Education Program 
    10524 Euclid Avenue
    Cleveland, Ohio 44106-6026
  3. Fax the 2019 Documentation form with your credit card number to 216.844.8133 or 216.201.6749.
  4. Phone 216.983.1239 or 800.274.8263 with the information requested on the form and your credit card number.

Location + Accommodations

The course will be held at the DoubleTree by Hilton Cleveland East Beachwood, 3663 Park East Drive, Beachwood, Ohio, at the Chagrin Boulevard exit off of I-271. Call the DoubleTree by Hilton directly at 216.464.5950 to make your reservations. A block of rooms has been reserved. Medical Documentation is the group name.

See map