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Medical Record: The Legal Document (2025 Update)
Course Overview
A patient's medical record serves as a critical piece of care, communication, and legal processes. Understand the core pieces of the medical record and how to obtain them to protect the patient and the practice.

Those who are students in a CAAHEP- or ABHES-accredited medical assisting program at any point in time are not eligible to participate in the ABR-OE program. Also, those who at any point in time have held the CMA (AAMA) credential (or its predecessor credential, CMA) are not eligible for the ABR-OE.

Visit the AAMA website for more information on eligibility and application policies.
Course Information
Course Description
Accurate medical records support safe, coordinated patient care while protecting patients, health professionals, and medical practices. This course examines the medical record as both a clinical communication tool and a legal document. Learners will review strategies for collecting and documenting complete patient information, applying the five Cs of effective documentation, correcting errors appropriately, and maintaining confidentiality.

Learners will also explore common record components, SOAP and problem-oriented documentation formats, and the legal consequences of incomplete or altered records. Through practical guidance, this course reinforces the medical assistant’s role in creating clear, objective, timely, and secure documentation throughout the patient’s care.

Learning Objectives
As a result of completing this course, you will be able to...
  • Explain how medical records support patient care, communication, reimbursement, and legal protection.
  • Apply the five Cs when documenting patient information in the medical record.
  • Identify appropriate procedures for correcting errors in paper and electronic records.
  • Compare SOAP and problem-oriented medical record formats.
  • Recognize practices that protect patient confidentiality and reduce legal risk.
Course Contributors
Mark Crawford
Author, "Medical Record: The Legal Document".
Intended Audience
This course is intended for medical assistants, CMA (AAMA) professionals, and other ambulatory care staff who collect, document, manage, or protect patient information. It supports professionals seeking to strengthen documentation practices, promote continuity of care, maintain confidentiality, and reduce preventable clinical and legal risks.
Retake Information
Please note that retakes for this online course require repurchase.
Summary
Availability:
On-Demand
Access expires 14 days after start
Cost:
Member: $20.00
Nonmember: $30.00
CEU Offered:
2 Gen/Adm/Clin CEUs
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