Nursing Documentation: Legally-Proven Strategies to Keep You Out of the Courtroom

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Handouts/Brochure

Speaker

Rachel Henderson, PhD, MS, RN, HCRM Related seminars and products

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Rachel Henderson, PhD, MS, RN, HCRM, is an expert speaker on topics focused on legal aspects of healthcare, nursing documentation, and regulatory compliance. Her 22 years as a legal nurse consultant, inpatient clinical nurse specialist and healthcare risk manager (HCRM) bring life to her presentations by sharing real case scenarios. She is a member of the National Speakers Association (NSA) and past president of the Florida Speakers Association (FSA). She is a published author in peer-reviewed journals and textbooks. In addition to owning a medical and legal consulting business, she has her PhD in Public Policy and Administration: Law and Policy. Rachel works with law firms and healthcare organizations, evaluating medical records for compliance with standards of care and applicable regulations. She has been an expert witness for medical negligence cases for both the plaintiff and the defense.

Speaker Disclosures:
Financial: Dr. Rachel Henderson has employment relationships with Medical Legal Concepts, Florida SouthWestern State College, and Palm Beach State College. She receives royalties as a published author. Dr. Henderson receives a speaking honorarium and recording royalties from PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Dr. Rachel Henderson is a member of the American Association of Critical Care Nurses, the American Society of Healthcare Risk Managers, and the American Society of Professionals in Patient Safety.

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Outline

1. Setting the Stage
   1. Many people read medical records during a lawsuit
   2. Medical records are just as important as testimony
2. Legal and Ethical Implications of Documentation
   1. Purpose of the medical record in the courtroom
   2. “Get it right the first time”
   3. Standards of documentation
   4. How to recognize deviations from the Standard of Care
3. Risk Management & Documentation
   1. Incident reports
4. Admissible Forms of Nursing Documentation
   1. Common documentation mistakes
   2. Physician orders
   3. Assessment
   4. Plan of Care
   5. Medications
   6. Interventions
   7. Difficult, stressful or sensitive situations
   8. Patient education & responses
   9. Other formats of documentation
5. Nursing Charting Systems
   1. Narrative
   2. SOAP
   3. PIE charting
   4. Focus charting
   5. Charting by exception
   6. Considerations when using flow sheets
   7. Working with computerized medical records
6. Avoiding Legally Risky Documentation
   1. Credible evidence
   2. Recording events objectively
   3. Maintaining factuality & thoroughness
   4. Avoiding ambiguity
   5. Avoiding bias
   6. Abbreviations to avoid
   7. Late entries
   8. Personal notes
   9. Correcting errors
7. Documentation & Bioethical Dilemmas
   1. Code of ethics
   2. Telling the truth
   3. Universal principles of biomedical ethics
   4. ANA code for nurses
   5. End-of-life issues
   6. Informed Consent & Therapeutic Privilege
8. Malpractice and Documentation
   1. Absence of information
   2. Falsifying, tampering or covering up
   3. Consequences of tampering
   4. Forensic Document Examiner’s role in record review
9. Analyze a Real Case Scenario

Outline:

1. Setting the Stage
   1. Many people read medical records during a lawsuit
   2. Medical records are just as important as testimony
2. Legal and Ethical Implications of Documentation
   1. Purpose of the medical record in the courtroom
   2. “Get it right the first time”
   3. Standards of documentation
   4. How to recognize deviations from the Standard of Care
3. Risk Management & Documentation
   1. Incident reports
4. Admissible Forms of Nursing Documentation
   1. Common documentation mistakes
   2. Physician orders
   3. Assessment
   4. Plan of Care
   5. Medications
   6. Interventions
   7. Difficult, stressful or sensitive situations
   8. Patient education & responses
   9. Other formats of documentation
5. Nursing Charting Systems
   1. Narrative
   2. SOAP
   3. PIE charting
   4. Focus charting
   5. Charting by exception
   6. Considerations when using flow sheets
   7. Working with computerized medical records
6. Avoiding Legally Risky Documentation
   1. Credible evidence
   2. Recording events objectively
   3. Maintaining factuality & thoroughness
   4. Avoiding ambiguity
   5. Avoiding bias
   6. Abbreviations to avoid
   7. Late entries
   8. Personal notes
   9. Correcting errors
7. Documentation & Bioethical Dilemmas
   1. Code of ethics
   2. Telling the truth
   3. Universal principles of biomedical ethics
   4. ANA code for nurses
   5. End-of-life issues
   6. Informed Consent & Therapeutic Privilege
8. Malpractice and Documentation
   1. Absence of information
   2. Falsifying, tampering or covering up
   3. Consequences of tampering
   4. Forensic Document Examiner’s role in record review
9. Analyze a Real Case Scenario

Objectives

Upon completion of this self-study package, you will be able to:

1. Describe the application of the Nurse Practice Act/Laws to documenting care of patients.
2. List ten ways to keep your documentation notes and charts out of the courtroom.
3. Summarize the common documentation mistakes and how to avoid and/or correct them.
4. Integrate the correct practices into your documentation notes to keep your license unblemished.
5. List at least three ways to safeguard electronic documentation.
6. Compare and contrast the different forms of nursing documentation and how they are used in the courtroom.
7. Utilize actual medical malpractice cases to learn how to improve your documentation.
8. Demonstrate how to document precisely and completely when situations are sensitive and/or stressful.

Target Audience

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