Rachel Cartwright-Vanzant – Nursing Documentation

During this time,-depth, interactive seminar, you will have the opportunity to review real court cases and learn from the actual testimonies provided by nurses’ depositions. Rachel Cartwright-Vanzant

Rachel Cartwright-Vanzant – Nursing Documentation

Description of the Course:

Your documentation would be sufficient to protect against legal liability if required to testify in court regarding the care that you provided to a person. Your documentation should allow you to accurately and precisely describe the standard of care that you gave to the patient, even if it was years or months later. You don’t want to miss this opportunity if you aren’t sure!

During this time,-depth, interactive seminar, you will have the opportunity to review real court cases and learn from the actual testimonies provided by nurses’ depositions. Rachel Cartwright-VanzantAn independent legal nurse consultant with more than 28 year of experience in management, clinical and consulting will provide the information that you need to ensure your documentation is accurate, handwritten or digital.-Written or electronic, it represents a level of care that meets applicable standards.

Learn how to avoid risky documentation, and how you can integrate practices that will preserve your license. The information you will learn can be applied immediately to your practice and could save you from going to court.

Objectives:
After completing this self-assessment,-Study package will allow you to:

1. Please describe the Nurse Practice Act/Laws used to document the care of patients.
2. Here are ten ways you can keep your charts and documentation out of the courtroom.
3. Summarize common errors in documentation and the steps to correct them.
4. Make sure to include correct practices in your documentation notes so that your license is not damaged.
5. There are at least three ways that electronic documents can be protected.
6. Compare and contrast different types of nursing documentation and their use in court.
7. To improve your documentation, you can use actual cases of medical malpractice.
8. Demonstrate the ability to accurately and fully document situations that are stressful or sensitive.

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Outline:

1. Setting the Scene
   1. During a lawsuit, many people will read medical records.
   2. Just as important are medical records as is testimony.
2. Legal and ethical implications of Documentation
   1. The purpose of the medical record in court
   2. “Get it right the first time”
   3. Standard for documentation
   4. How to identify deviations from Standard of Care
3. Risk Management & Documentation
   1. Incident reports
4. Acceptable Forms Nursing Documentation
   1. Common documentation mistakes
   2. Physician orders
   3. Assessment
   4. Plan of Care
   5. Medications
   6. Interventions
   7. Situations that are difficult, stressful, or sensitive
   8. Patient education & responses
   9. You can also use other formats of documentation
5. Nursing Charting Systems
   1. Narrative
   2. SOAP
   3. Charting PIE
   4. Focus charting
   5. Charting with exceptions
   6. Considerations for flow sheets
   7. Computerized medical records
6. Avoiding Risks Documentation
   1. Evidence that is credible
   2. Objectively recording events
   3. Maintaining factuality & thoroughness
   4. Avoid ambiguity
   5. Avoiding bias
   6. Avoidance of abbreviations
   7. Late entries
   8. Personal
   9. Correcting errors
7. Documentation & Bioethical Dilemmas
   1. Code of ethics
   2. Truth telling
   3. Biomedical ethics: Universal principles
   4. ANA code for nurses
   5. End-Of-Life issues
   6. Informed Consent & Therapeutic Privilege
8. Malpractice and Documentation
   1. Information is missing
   2. Fake, tampering, or covering up
   3. Tampering can have serious consequences
   4. Forensic Document Examiner’s role in record review
9. Analyze a Real Case Scenario