The Ethics and Art of Chart Noting
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
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 |
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.
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 PharmacyThe 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 ANCCUPMC 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