Best Practices in Nursing Documentation: Writing Effective and Legal Proof Notes
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CD & Manual | ||
| 389038TMX | $99.00 USD |  |
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96 Min. Audio MP3 - No shipping cost | ||
| 389038POD | $99.00 USD | |
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| Credit Details | |||
| What is a Podcast? | |||
Benefits
Long gone are the days that nurses and other health care providers hand-wrote cryptic notes on essay paper-like chart pages that rarely were ever looked at again. Long gone, also, are the days that physicians would only look at labs, reports and other physician's notes, expecting the nurse to call to the physician's attention anything important about the patient so they didn't have to read nurses' notes. Electronic records are a reality that has not yet fully come to fruition. The information documented about a patient will live on and be seen by a multitude of individuals. It has become even more important to document accurately, succinctly, intelligibly and professionally. This live audio conference will place documentation of patient care in its rightful place, summarize its multiple purposes, describe appropriate documentation, and highlight pitfalls of bad documentation and its consequences. This program will introduce you to how the legal system uses documentation, techniques to avoid problems and what you might be required to do at some time in the future with respect to your documentation or lack thereof. The standards that are applied to documentation will also be discussed briefly. Last, but not least, you will be able to ask questions and will learn from unfortunate examples of others' documentation and the consequences of those failures.
Learning Objectives:
- You will be able to describe appropriate and incomplete documentation of patient care.
- You will be able to identify consequences of incomplete documentation.
- You will be able to recognize the purposes of patient care documentation.
- You will be able to discuss how the legal system uses documentation.
- You will be able to respond to questioning of patient care documentation.
Agenda
| Medical Record or Medical Information | |
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| Purposes of Documentation of Medical Care | |
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| New ICD 10 and Legal Implications | |
| HIPAA and Selected Impact on Documentation | |
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| Documentation – the Good, the Bad and the Plain Ugly | |
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| The Medical Record as Evidence | |
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| Questions And Answers |
Faculty
Diane M. Janulis, J.D., M.S.N., B.S.N., JurisMedicaGroup
Diane M. Janulis, J.D., M.S.N., B.S.N.
- Principal, JurisMedicaGroup
- Retired counsel at King & Spalding LLP in Atlanta
- Practice concentrates on pharmaceutical products liability defense, including expert witnesses and scientific issues
- Formerly practiced in areas of medical malpractice defense, health care risk management and health care law
- Conducted more than 300 seminars on medical and legal issues both in the U.S. and internationally
- Wrote several articles, chapters and a text on medical professional liability issues, documentation and medical records
- Member of the American Health Lawyers Association, the American Bar Association, Sigma Theta Tau and numerous other professional societies and associations
- Practiced nursing for 13 years prior to entering law school
- Testified as expert witness regarding nursing documentation
- J.D. degree, University of Maryland
- M.S.N degree, University of Pennsylvania
- B.S.N. degree, Georgetown University
These Materials are Designed For
This live audio conference is designed for nurses, nurse practitioners, physician assistants, directors of nursing, physicians, medical administrators, risk managers and attorneys.
| CD & Manual | - CD Set with bound 38 page manual |
| Podcast | - 96 Minute MP3 with 38 page electronic manual - Immediate Access and No Shipping Cost |
