Managing Patient Information: Strategies for Advanced Practice Clinicians


This program covers the patient information system, specifically documentation of patient information in the medical record.  Many times, insufficient documentation results in the provider not being able to find information needed to guide clinical decision-making. Adequate documentation will enhance patient care by ensuring that patients receive the care necessary and may prevent a mis- or delayed diagnosis.

Course ID #: ANE 221126.0 Issue Date: 7/14/2022 Expiration Date: 7/14/2025

Description of the Professional Practice Gap (PPG)
Findings from 773 patient safety risk assessments performed by The Doctors Company revealed that issues related to patient information were identified in 6 percent of the surveys (n = 46) of assessed practices. The following chart provides the breakdown of processes: 
The two areas assessed at the time of survey were if the patient completed a written history form and a current problem list.  Upon further review of closed claims, it was determined that patient information should be more intensely surveyed in the future.

Learning Outcome
Learners will have an increase in or support of their knowledge and skills related to best practices for managing patient information. Indication of increased confidence regarding their understanding or and ability to perform best practices.

Learning Objectives

After completing this activity, learners will be able to:

  • Identify the gaps in the patient information system.
  • Develop improvement strategies that address the top three gaps.
  • Apply a process improvement method to implement changes to address and close identified gaps.
  • Evaluate the changes made to the patient information system.

Course Developers

Kimberly Hathaway, MSN, RN, CPHRM, CPHQ, Director Patient Safety Healthcare Quality & Risk Management, The Doctors Company
Johanna Lackner, MPH, MSW, Senior Director, Continuing Professional Development, Department of Patient Safety and Risk Management, The Doctors Company

Accreditation and Disclosure Statements

The Doctors Company is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.

The Doctors Company designates this activity for a maximum of 0.5 nursing contact hourLearners should claim only the credit commensurate with the extent of their participation in the activity.

No individual in a position to control or influence the content of this activity has reported relevant financial relationships with commercial interests. No commercial support was provided for this activity. 

Disclaimer Statement

This program is being offered for informational and educational purposes only from a Patient Safety Risk Management perspective and does not constitute legal advice. Laws vary from state to state, actual clinical situations often involve subtle differences and nuances from program scenarios or recommendations, and the recommendations provided in this activity may not apply to all practice situations. In complex circumstances, which present significant potential for an adverse event or litigation, TDC and the faculty recommend you consult directly with your corporate or personal counsel for professional legal guidance. 

Complies with State Requirements

Please SEE the Registered Nurse and Licensed Practical Nurse CE Requirements by State.

Technical Requirements

The activity is best experienced using the most current browser: Firefox, Chrome, Safari, or Microsoft Edge. Internet Explorer is not supported on this platform. All activities featuring audio must have a speaker. To view graphic images and references that appear in separate "pop-up" windows, JavaScript and session cookies must be enabled on your computer. Adobe Acrobat Reader may be required for certain activities.

Contact Us

If you have questions, contact or call 800.421.2368.


Visit our Resource document for this program.