The Ethics and Art of Chart Noting

Pittsburgh, PA US
August 30, 2023

The medical chart documents a particular story about the patient, and the chart note author makes numerous decisions and value judgments in the process of prioritizing (and deprioritizing) certain information and choosing some language over others. The chart note is a powerful communication tool, and especially since the 21st Century Cures Act, it has important implications for the therapeutic relationship with the patient. This talk offers insights and techniques for minimizing bias, addressing patient vulnerability, and building a stronger therapeutic alliance through chart noting.

Target Audience

ISD Clinical Staff

Learning Objectives

ANCC / SW / EMT & PARAMEDICS:

1.  Discuss the ethical and professional challenges that accompany open notes with the 21st Century Cures Act

2.  Analyze how bias, explicit or implicit, can enter the chart note

3.  Describe best practices for clear, effective, and fair documentation in the medical record

PHARMACY:

1.  Understand the implications of the 21ST Century Cures Act on patient-centered care when documenting in the patient's electronic medical record

2.  Reflect on individual ability to provide clear, effective and fair documentation in the patient's medical record

Course summary
Available credit: 
  • 1.00 ACPE Pharmacy
    The UPMC Center for Continuing Education in the Health Sciences is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a Provider of continuing pharmacy education.
  • 1.00 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 1.00 ASWB
  • 1.00 Attendance
Course opens: 
07/21/2023
Course expires: 
09/29/2023
Event starts: 
08/30/2023 - 10:00am EDT
Event ends: 
08/30/2023 - 11:00am EDT
Add to calendar: 

Program begins at 10:00am and ends at 11:00am.  Total Education Time = 1 Hour(s)

TIME

CONTENT

PRESENTER

10:00 to 10:20am

Review how ethical and professional challenges accompany open notes with the 21st Century Cures Act

Laura Guidry-Grimes, PhD, HEC-C

10:20 to 10:40am

Discuss how bias, explicit or implicit, can enter the chart note.

Laura Guidry-Grimes, PhD, HEC-C

10:40 to 11:00am

Review best practices for clear, effective, and fair documentation in the medical record.

Laura Guidry-Grimes, PhD, HEC-C

UPMC Health Plan
600 Grant Street
Pittsburgh, PA 15219
United States
Laura Guidry-Grimes, PhD, HEC-C
Associate Staff Bioethicist, Cleveland Clinic
 
Laura Guidry-Grimes, PhD, HEC-C is an Associate Staff Bioethicist at Cleveland Clinic with regional responsibilities at Lutheran and Marymount Hospitals in northeast Ohio. She is also a Clinical Assistant Professor at Cleveland Clinic Lerner College of Medicine. Previously, she worked as faculty and as a clinical ethicist for the University of Arkansas for Medical Sciences and Arkansas Children's Hospital in Little Rock, AR, and she started her career at MedStar Washington Hospital Center in Washington, DC. Her research interests focus on how patients can be rendered vulnerable in clinical settings, disability bioethics, and psychiatric ethics. She received her PhD in Philosophy from Georgetown University in 2017.

In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Pharmacy (CPE)
This knowledge-based activity provides 1 contact hours of continuing pharmacy education credit(s).   Pharmacists Only: As required by the ACPE, credits will be uploaded to the National Association of Boards of Pharmacy (NABP). It is the responsibility of the pharmacist/pharmacy technician to provide the correct NABP Board ID and DOB in their UPMC continuing education account, http://cce.upmc.com   and complete the evaluation by the required due date. Credit will not be uploaded to the NABP if the process is not complete by the required due date.
 
Nursing (CNE)
The maximum number of hours awarded for this Continuing Nursing Education activity is 1 contact hour(s).

CCM CE will be provided:  1 CE - CCM COA will be sent via email from UPMC Health Plan nurse planner approximately 6-8 weeks following the live date of the course.

This activity is eligible for endorsed credit for UPMC Health Plan EMTs and Paramedics.  Complete ETHOS course work, obtain the attendance certificate, and submit to EMS governing body for 1 CE credit(s).

As a Jointly Accredited Organization, University of Pittsburgh is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. University of Pittsburgh maintains responsibility for this course. Social workers completing this course receive 1 continuing education credit(s).

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

NOTE:  Paramedic/EMT CE is approved for any activity in which ANCC (nursing CE) is approved.  This is per Heather Bogdon and Christie Hempfling

Available Credit

  • 1.00 ACPE Pharmacy
    The UPMC Center for Continuing Education in the Health Sciences is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a Provider of continuing pharmacy education.
  • 1.00 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 1.00 ASWB
  • 1.00 Attendance
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