Legal Requirements of Medical Records
Remedial Self Study Course | On Demand | 6 Non-Medical Credit Hours
This course is designed for veterinarians needing specialized medical recordkeeping continuing education pursuant to a directive from their state veterinary board. This course emphasizes the legal requirements for medical record keeping, the VCPR, and confidentiality. The course highlights examples of good and poor medical records as well as case examples. If you are required by your state veterinary board to take specific medical record keeping CE, this course is for you. If you are looking for general CE for regular license renewal, check out Efficient Medical Recordkeeping for Veterinarians.
Learning Objectives
- Describe which practice records compose the medical record
- Understand the doctrine of informed consent and its effect on veterinary practice and client communications
- Describe what information should be included in the medical record.
- Describe efficiency and effective techniques used to create high quality records
- Understand the VCPR, confidentiality requirements, storage requirements and other state law requirements
- Identify common mistakes in medical records and their impact on court case
Course Curriculum
-
Startdrip 0 - State Medical Records Laws
-
Startdrip 1 - Federal Regulations (4:23)
-
Startdrip 2a - State Law Requirements: California Part 1 (8:51)
-
Startdrip 2b - State Law Requirements: California Part 2 (10:57)
-
Startdrip 3 - State Law Requirements: Texas (7:49)
-
Startdrip 4 - Admissibility Requirements (7:31)
-
Startdrip 5 - Evidentiary Presumptions (7:17)
-
Startdrip 6a - Informed Consent Part 1 (7:04)
-
Startdrip 6b - Informed Consent Part 2 (10:22)
-
Startdrip 6c - Informed Consent Part 3 (10:18)
-
Startdrip 7 - Storage and Retention (7:54)
-
Startdrip 1 - The SOAP format (6:20)
-
Startdrip 2 - The HEAP format (7:32)
-
Startdrip 3 - The E in HEAP (5:52)
-
Startdrip 4 - The A in HEAP Part 1 (3:34)
-
Startdrip 5 - The A in HEAP Part 2 (5:34)
-
Startdrip 6 - The P in Heap (2:26)
-
Startdrip 7a - Charlie Case Example Part 1 (9:20)
-
Startdrip 7b - Charlie Case Example Part 2 (9:02)
-
Startdrip 7c - Charlie Case Example Part 3 (6:56)
Instructed by
Dr. Roasa has earned his veterinary and Master’s degrees from Texas A&M University and his law degree from the University of Nebraska. He practiced veterinary medicine in settings ranging from from a corporate practice in Phoenix, to referral emergency, to traveling non-boarded surgery. He has owned, operated, and sold small animal, mixed animal, and ER practices in multiple states. Since 2016 he as operated a law practice that exclusively services veterinarians and their practices. Additionally, he teaches law, ethics, business, and career development in 17 veterinary colleges across the US. He is the past president of the American Veterinary Medical Law Association and a national co-advisor to the Veterinary Business Management Association. Currently, he serves as a consultant in the VIN Regulatory and Legal folder and Practice Management folder.