Description
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.
Date: 2019-03-01 Start Time: End Time:
Learning Objectives
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
Rachel Cartwright, Ph.D., M.S., RN, LHRM-Medical Legal Concepts, LLC
