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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.

84 minutes
Certificate of Completion
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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

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.

All of your training, right here at Lorman

All of your training, right here at Lorman.

Pay once and get a full year of unlimited training in any format, any time!

  • OnDemand Courses
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Additional benefits include:

  • State Specific Credit Tracker
  • All-Access Pass Course Concierge

Questions? Call 877-296-2169 to speak with a real person.

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Product ID: 401705
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