Course: Risk Management Focus: Documentation, 3rd Edition
Author: Rosemary Gafner and James Schutte
AMA PRA Category 1 credits: 1
Estimated Hours to Complete Course: 0.75
Estimated Minutes to Complete Test: 15
Course Release Date: 3/1/2018
Course Expiration Date: 12/31/2021
How traditional and electronic health records can affect liability


NOTE: All Medrisk courses are approved for CME credit, but not all are approved for insurance discounts or medical board remediation. If you are enrolling in a course for an insurer, university or medical board, you should check with them to make sure that the course you are selecting is approved.

Risk Management Focus
Documentation, 3rd Edition


The human and financial toll of poor documentation practices is staggering. Every year, thousands of patients die or are injured by mistakes like the failure to leave clear medical instructions in the chart, specialty reports that are provided too late and are not brought to the attention of the attending physician, and confusing medication orders that resulted in the wrong drug or the wrong dosage being delivered.


Upon completion of this course, you should be able to:

1.  Describe the inherent dangers of using the “copy and paste” function of the electronic health record.
2.  Explain the significance of embedded metadata in the electronic health record.
3.  Protect patient health information when using mobile devices to access their EHRs.


Target Audience

All healthcare providers.


This is a self-study course consisting of text and CME test.  Physicians should read the course content, answer the test questions and submit the answers for scoring.  Those who complete the course with a score of 80 percent or higher will earn a maximum of 1 AMA PRA Category 1 creditTM.


This course was developed by Rosemary Gafner, Ed.D. and James E. Schutte, Ph.D.  Their CVs are available at

CME Information

Medical Risk Management, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing education for physicians.  Medical Risk Management, Inc. designates this  enduring material  for a maximum of 1 AMA PRA Category 1 creditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is valid for release March 1, 2019 and expires on December 31, 2021.

Estimated time to complete this activity: 1 hour.

Commercial Support

This activity was developed solely by Medical Risk Management, Inc. without any commercial support.


Neither Dr. Gafner nor Dr. Schutte have anything to disclose.

Please check with your insurance carrier for approved courses before registering.  Courses not approved by your insurance carrier will not be accepted by them for any discounts they may offer.