Learn to identify resources and understand methods for documenting patient condition and progress.
Health care providers have a duty to maintain an accurate and complete recording of all relevant events. Patient care and treatment which comports with acceptable medical and nursing standards of practice is of little value if not properly documented. Evaluate your personal documentation pattern and determine vulnerabilities that may exist. Immediately implement strategies that will decrease your exposure while enhancing the evidence of continuity and quality patient care.
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Why Lorman?
Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.
Agenda
Legal and Ethical Implications of Proper Documentation
Hospital Duties Owed to Patients
Liability; Personal and Managerial
Working With Computerized Medical Records
Delegation
Negligence
Failure to Meet Standards Established by Law
Medical Records Are Just as Important as Testimony in Trial
Know What to Chart and Know How to Chart
Charting Challenges: When Things Go Wrong
Fact Rule; Sample; OPQRST; Senses
Standards of Documentation
Implications of Evidence-Based Practice
Sources for Documentation Standards
Self-Serving Documentation
Falsification of Medical Records
Common Documentation Mistakes
Advanced Practice Nurses Scope of Practice
Defensive Strategies
Avoid Legally Risky Documentation
Effective Communication
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Why Lorman?
Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.
Credits
OnDemand Course
This course was last revised on March 1, 2019.
Call 1-866-352-9540 for further credit information.
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Why Lorman?
Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.
Faculty
Rachel Henderson, Ph.D., MS, RN, HCRM
Medical Legal Concepts, LLC
- Founder and CEO of Medical Legal Concepts, LLC
- National speaker on healthcare-related topics including regulatory compliance, in-person, webinar, and virtual
- Provides consultation for healthcare institutions addressing quality and compliance issues
- Author of several publications related to legal aspects of documentation and standards of care
- Past-President of Florida Speakers Association; and member of National Speakers Association, American Nurses Association, and American Society of Healthcare Risk Managers
- Owner of Medical Legal Concepts Academy https://academy.medicalegalconcepts.com/
- Ph.D. degree in public policy and administration: law and public policy; master’s degree in nursing; health care risk manager
- Can be contacted at 800-259-8058 or [email protected]
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Why Lorman?
Over 37 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.
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