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Home > Audio Learning Center > In Defense of Good Medical Record Documentation

In Defense of Good Medical Record Documentation

Date:Tuesday, August 13, 2019
Time:12 noon to 1:00 p.m. Central Time
Course fee:$99
Presented by: Linda D’Spain, CMPE, CMC, CMIS, CMOM, CMCO

Webinar/Audio Conference FAQs

Documentation and management of patient medical records is a tremendous responsibility when you consider that mistakes could cause harm or death to a patient. Left unchecked, improper documentation will eventually lead to major compliance issues. Yet many practice managers are not well-versed in this area.

Practice Management Consultant, Linda D’Spain, has important information for managers and compliance officers charged with protecting the financial interests in a medical office. If you feel like a fish out of water when it comes to analyzing your billing patterns, then don’t miss this webinar!

Accurate reimbursement and risk management are closely aligned to proper documentation. When the documentation does not justify the codes selected, problems can snowball creating financial problems. They can also flag your practice for an audit.

Software cannot replace human verification! Linda will explain the steps that you can take now to ensure that your documentation is defensible and includes all five elements required for proper medical documentation.


  • Responding to a MAC regarding an aberrancy that exists within your practice
  • Statistics that indicate the danger of excessive use of EHR templates or cloning
  • Case studies illustrating documentation errors or omissions and the outcomes
  • Tools to improve documentation in your practice
  • An overview of some of the most common mistakes made in documentation

Medicare Administrative Contractors (MAC) regularly monitor billing and claim submission data for unusual patterns. Your patient medical record must reflect the relevancy of medical necessity and justify the code selection. If the services billed to payers do not follow OIG and third-party payers guidelines, your practice may be targeted for an external audit.

Continuing Education Units (CEUs)

PMI CEU APPROVED Earn 1 PMI CEUs for attendance at this program. Practice Management Institute grants CEUs for its certified professionals based on total number of instructional hours (1 CEU per hour of classroom instruction). CEUs may be applied to annual recertification requirements, as directed in the certification renewal requirements for your credential(s).

If you are seeking CEU credits for other certifications or organizations, please contact your organization for pre-approval and credit guidelines. A certificate of attendance will be provided.

Please read below before completing your webinar registration.

Have you heard about PMI's TOTAL ACCESS Webinar subscription program? TOTAL ACCESS puts a full library of training in the hands of your entire staff for a monthly fee of just $249. TOTAL ACCESS is the newest way to develop your own talent, without leaving the office to attend training classes. It's also the fastest way to bring both experienced and new staff up-to-date on current issues.

Sign up now and you'll receive this webinar plus the following benefits for as long as you subscribe: access codes to all upcoming live webinars and unlimited access to the TOTAL ACCESS Library, more than 300 hours of on-demand, pre-recorded training sessions on over 100 topics relevant to medical office coding, billing, compliance, management, front desk, and much more. It's a GREAT VALUE!

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About the Presenter

Linda is President of D’Spain Consulting and conducts training nationally with physician practices, hospitals and medical societies on healthcare reimbursement, documentation guidelines, procedural and diagnostic coding, financial management, human resources, medical office management and compliance with fraud and abuse, OSHA, and HIPAA. She has more than 30 years of experience in medical practice management where she has maintained broad responsibilities in business and clinical operations, financial management, governance and organizational dynamics, human resource management, marketing, customer service, compliance, information system management, mergers and acquisitions and risk management.

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