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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 32 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 32 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 Webinar

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.
     

Audio & Reference Manual

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MP3 Download

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Why Lorman?

Over 32 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-Vanzant, PhD, MS, RN, LHRM

Rachel Cartwright-Vanzant, PhD, MS, RN, LHRM

Medical Legal Concepts, LLC

  • Owner and CEO of Medical Legal Concepts, LLC
  • Works with law firms and health care organizations evaluating medical records for compliance with standards of care and applicable regulations
  • Keynote: Patient Safety Conference: Martinsburg WVA (2015); Coveys Risk Management Conference (2015)
  • Licensed as a registered nurse and a health care risk manager with more than three decades of clinical, consulting and professional speaking experience
  • An innovative educator and she has the ability to make complex concepts understandable and clinically useful
  • Published writer in peer reviewed journals and textbooks
  • Has been an expert witness for medical negligence cases for both the plaintiff and the defense
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Why Lorman?

Over 32 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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