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.
Rosale Lobo – Nursing Documentation
Description:
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
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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.
