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OnDemand Course

Proper Documentation to Accurately Reflect Patient Progress and Enhance Patient Care

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.

Runtime: 84 minutes
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Why Lorman?

Over 33 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 33 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.

  • RN - ANCC 1.4
     
  • This Enduring Material was approved by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Participants receive 1.4 contact hours for this program. To receive a certificate of successful completion, you are required to complete and return an evaluation form. Planning Panel Members are: Michelle Shepherd. There are no conflicts of interest to report. There was no commercial support received for the planning of this program. No endorsement of products or off-label use will occur at this program.
     
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Why Lorman?

Over 33 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 Cartwright, Ph.D., M.S., RN, LHRM

Rachel Cartwright, Ph.D., M.S., RN, LHRM

Medical Legal Concepts, LLC

  • Founder and CEO of Medical Legal Concepts, LLC
  • National speaker on health care-related topics including regulatory compliance, in-person, webinar, and virtual
  • Provides consultation for health care institutions addressing quality and compliance issues
  • Author of several publications related to legal aspects of documentation and standards of care
  • President-elect, Florida Speakers Association; and member of National Speakers Association, American Nurses Association, and American Society of Healthcare Risk Managers
  • Host and producer of the https://legalnurseconsultantsummit.com/
  • Owner of Medical Legal Concepts Academy https://mlcacademy.thinkific.com/
  • Ph.D. degree in public policy and administrations: law and public policy; master’s degree in nursing; licensed health care risk manager
  • Can be contacted at 800-259-8058 or [email protected]
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Why Lorman?

Over 33 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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Product ID: 401705
Published 2019
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Available in Multiple Formats

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