Expert and certified legal nurse consultant Rosale LoboLearn how to create a systematic approach for documentation that will protect you, your patients, as well as your license.
Rosale Lobo – Nursing Documentation
Description:
Expert and certified legal nurse consultant Rosale LoboDr. c, MSN, RN CNS, LNCC to learn how to create a system for documentation that protects you, your patients, and your license. Learn how to avoid potentially dangerous documentation, how to use electronic documentation correctly and how to make it meaningful. Rosale This guide will help you overcome the most difficult documentation problems.
This is a dynamic one-Day Program will provide tools to protect your documentation such as:
- Tips to save time when using EMR and electronic documentation
- Documentation of compliance, incident reports, adverse events
- To make data collection easier, we have created sample strategy worksheets
- Federal government requests for charting on the basis of meaningful use criteria
- Social media, email and texting: Dangers
- Case studies and examples of the correct and wrong documentation
Would you like to be contacted? Rosale Lobo – Nursing Documentation
?
OUTLINE
The components of Documentation
- Guidelines
- Interpretation
- Make mistakes
- Education
- Social Networking
- Indirect Care
Electronic Nursing Documentation
- American Recovery and Reinvestment Act
- Meaningful use
- Health Insurance Portability and Accountability Act, (HIPPA).
- Use of electronic documentation in a risky manner
- Email, texting, and social networking: Dangers
Electronic Medical Records Strategies (EMR)
- Time Management
- Liability
- Software Knowledge
- Meaningful use
Reimbursement Documentation
- Medicare/Medicaid Changes
- Incentives and meaningful usage criteria
- EMR Timelines
- Hospital Acquired Conditions
Documentation When things go wrong
- Compliance
- Regulations
- CMC
- Incident Reports
- Adverse Events
- Risk Factors
Ethical Issues
- Truth Tellers
- Standards
- Deviations
- Errors
- Omissions
- Communicating
- Corrections
Avoiding Risky Documentation
- Evidence of credibility
- Avoiding Ambiguity
- Objectively recording events
- Late Entries
- Correcting Errors
What if the worst ever happens?
- Duty / Breach of Duty
- Nurse Practice Act
- State Board of Nursing
- Depositions
Exemples and case studies Documentation
OBJECTIVES
- Identify a strategic system for nursing documentation.
- Define how documentation is used in deciding if you are guilty of a crime or innocent in a lawsuit.
- Recognize the significance of use criteria in order to meet your reimbursement needs.
- To ensure reimbursement, list the best ways to use computerized records.
- How to avoid risky behavior while using social media and other forms electronic communication
- Define the best practices and standard of care in documenting incidents and adverse events.
- Make sure to incorporate the best practices in your documentation so that your license is not damaged.
- These are the most common mistakes in documentation. Let’s look at how to fix them.
Course Features
- Lectures 0
- Quizzes 0
- Duration Lifetime access
- Skill level All levels
- Language English
- Students 0
- Assessments Yes
