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Module 4: Documentation & Privacy
Write documentation that is objective and defensible, correct errors properly, and protect patient information in the situations where it is most often lost.
2
Lessons
44
Minutes
Practice
Files Included
Beginner
Level
What You'll Learn
- Objective versus subjective documentation, and why interpretation is out of scope
- How to correct an error while preserving the audit trail
- The everyday situations that cause most privacy breaches
- Handling records requests and family members' questions
Real-World Scenario
You write 'patient seems anxious and is probably overreacting to mild symptoms.' Two years later that sentence is read aloud in a deposition, about a patient whose symptoms turned out to be significant.
Lessons
Complete each lesson in order. Watch the video, review the notes, and finish the challenge.
Lesson 1⏱ 24 min
📝Documenting in the Electronic Health Record
Write documentation that is accurate, objective, and defensible, and understand what the record is actually for.
Lesson 2⏱ 20 min
📝Records Management and Patient Privacy
Handle records and patient information in line with HIPAA, and recognize the everyday situations where privacy is most often lost.