“If you don’t write that, you could lose your license,” or “If you write that, you could lose your license.” This was something I heard during my entire nursing career and I never really knew what it meant. I was the nurse who was called into the office to explain an entry, clarify a comment, or “fix” something that had already been noted. My thought was, “if you just tell me what I’m supposed to chart, I’ll do it.”
In addition to supervisor or facility expectations, there are requirements now in place for electronic charting by the Center for Medicare and Medicaid Services (CMS). In addition, healthcare is highly regulated and full of reimbursement woes, which often are connected with the documentation. What’s a nurse to do…? Rosale Lobo, PhD(c), MSN, RN, CNS, LNCC, has the answers!
Learn the meaning of being a non-fiction story teller - nurses have been voted the most trusted professionals for years because we are truth tellers. We are educated to care for our patients with compassion and ethics, so why has it become difficult to chart according to our personal belief system. Learn the truth behind documentation standards.
Charting for innocence or guilt - it is no secret that charting can lead to a trip to court but how does that actually happen. How does this path become something nurses fear? This 3-day boot camp will take you down the path to litigation and demonstrate why certain actions or inactions could jeopardize your chances of appearing innocent.
Did you deviate from the standard of care? How does a person deviate from the standard of care if there is no one there to witness it? Who determines that a nurse has deviated from the standard of care? Three days of intense learning about nursing documentation and litigation will transform the way you think about your nursing practice and the way you document the care you provide.
This class is a must for all nurses. It is long overdue. You will definitely return to work with increased confidence to reduce your own professional risk. Don’t delay… register today before this class hits capacity and the opportunity to earn your certificate in nursing documentation is gone!
- Evolution of medicine, nursing and healthcare
- The essence of the story behind litigation
- The burden of proof
- The expert witness seals the deal
The Components of Documentation
- Social networking
- Indirect care
Electronic Nursing Documentation
- American Recovery and Reinvestment Act
- Meaningful Use
- Risky electronic documentation practices
- Dangers of email, social networking, and texting
Electronic Medical Record Strategies
- Time management
- Software knowledge/Informatics
Reimbursement and Documentation
- Medicare and Medicaid Changes
- Incentives for participation
- Hospital Acquired Conditions
Elements of a Lawsuit
- Plaintiff complaints
- Medical record review
- Timeline chronology
Documentation When Things Go Wrong
- Incident reporting
- Adverse events
- Risk factors
- Truth telling
- Standards that are within standards
- Deviations, real or perceived
- Errors of omission
- Errors of commissions
- Communicating clearly
Avoiding Risky Documentation
- Credible evidence
- Avoiding ambiguity
- Recording events objectively
- Late entries
- Correcting errors
What if the Worst Happens?
- Duty/Breach of Duty
- Nurse Practice Act
- State Board of Nursing
- Analyze how the nursing standards of care can come under scrutiny.
- Evaluate authoritative sources.
- Separate care plan and the care planning process.
- Explore a strategic nursing documentation system.
- Communicate how documentation is used to decide if you are innocent or guilty in a lawsuit.
- Explore how to prevent risky behavior when using social media and other forms of electronic communication.
- Inform how to use best practice and standard of care for documenting incident reports and adverse events.
- Analyze the Center for Medicare and Medicaid regulatory language on nursing documentation.
- Formulate a strategic tool for your standard of practice.
- Evaluate deposition proceedings.
- Analyze timeline chronologies.
- Determine defense and plaintiff allegations.
- Integrate the correct practices into your documentation to reduce litigation exposure.
- Explore the common documentation mistakes and how to avoid/correct them.
- Evaluate facility policy and procedures for potential risk.
- Graph the litigation timeline.
- Formulate deposition questions as the plaintiff and/or defense teams.
- Practice litigation language during mock depositions.