Join expert and legal nurse consultant, Rosale Lobo, PhD(c), MSN, RN, CNS, LNCC, to learn how to develop a systematic approach to documentation that will keep you, your patients and your license safe. You will learn how to identify and avoid risky documentation as well as how to correctly utilize electronic documentation and the correct technique for meaningful use. Rosale will show you step by step, how to overcome your most complex documentation questions and challenges.
This dynamic one-day program will include tools to safeguard your documentation including:
- Time saving tips for electronic documentation and EMR use
- Documenting compliance, incident reports, and adverse events
- Sample strategy worksheets for ease of data collection
- Federal government requests for charting based on meaningful use criteria
- Dangers with social media, email, and texting
- Examples and case studies of correct and incorrect documentation
OUTLINE
The Components of Documentation
- Guidelines
- Interpretation
- Mistakes
- Education
- Social Networking
- Indirect Care
Electronic Nursing Documentation
- American Recovery and Reinvestment Act
- Meaningful Use
- Health Insurance Portability and Accountability Act (HIPPA)
- Risky electronic documentation practices
- Dangers of email, social networking, and texting
Electronic Medical Records (EMR) Strategies
- Time Management
- Liability
- Software Knowledge
- Meaningful Use
Reimbursement and Documentation
- Medicare/Medicaid Changes
- Incentives and meaningful use criteria
- EMR Timelines
- Hospital Acquired Conditions
Documentation When Things Go Wrong
- Compliance
- Regulations
- CMC
- Incident Reports
- Adverse Events
- Risk Factors
Ethical Issues
- Truth Tellers
- Standards
- Deviations
- Errors
- Omissions
- Communicating
- Corrections
Avoiding Risky Documentation
- Credible evidence
- Avoiding Ambiguity
- Recording events objectively
- Late Entries
- Correcting Errors
What if the Worst Happens?
- Duty /Breach of Duty
- Nurse Practice Act
- State Board of Nursing
- Depositions
Examples and Case Studies of Documentation
OBJECTIVES
- Identify a strategic nursing documentation system.
- Describe how documentation is used to decide if you are guilty or innocent in a lawsuit.
- Recognize the meaningful use criteria to meet reimbursement needs.
- List how to best use features in computerized records to ensure reimbursement.
- Identify how to prevent risky behavior when using social media and other forms of electronic communication.
- Define how to use best practice and standard of care for documenting incident reports and adverse events.
- Integrate the correct practices into your documentation to keep your license unblemished.
- Summarize the common documentation mistakes and how to avoid and/or correct them.
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