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Digital Seminar

Patient Chart Reviews – with Actual Documentation Mistakes


Speaker:
Rachel Henderson, PhD, MS, RN, HCRM
Duration:
2 Hours 05 Minutes
Format:
Audio and Video
Copyright:
Aug 24, 2023
Product Code:
POS078616
Media Type:
Digital Seminar


Description

Patient safety is one of the paramount priorities in clinical settings. Patient safety is one of many reasons formal clinical documentation improvement programs were developed. The best way to prevent a documentation disaster is by recognizing the most frequent documentation errors and putting procedures in place to prevent them. The top four documentation mistakes are mixed messages, misuse of copy and paste in the electronic health record, incomplete or missing documentation, and misplaced documentation. High-quality patient documentation is crucial for ensuring quality care, continuity of care, and patient safety. Learning from the mistakes of others is effective in changing documentation practice patterns.

Credit

Planning Committee Disclosure - No relevant relationships

All members of the PESI, Inc. planning committee have provided disclosures of financial relationships with ineligible organizations and any relevant non-financial relationships prior to planning content for this activity. None of the committee members had relevant financial relationships with ineligible companies or other potentially biasing relationships to disclose to learners.  For speaker disclosures, please see the faculty biography.



* Credit Note - **

NOTE: Tuition includes one free CE Certificate (participant will be able to print the certificate of completion after passing the online post-test (80% passing score) and completing the evaluation). Instructional methods will include PowerPoint, didactic lecture, and others.

Continuing Education Information:  Listed below are the continuing education credit(s) currently available for this non-interactive self-study package. Program content is reviewed periodically per accrediting board rules for currency and appropriateness for credit. Credit approvals are subject to change. Please note, your state licensing board dictates whether self-study is an acceptable form of continuing education, as well as which credit types are acceptable for continuing education hours. Please refer to your state rules and regulations. If your profession is not listed, please contact your licensing board to determine your continuing education requirements and check for reciprocal approval. 
For other credit inquiries not specified below, please contact info@pesi.com or 800-844-8260 before purchase.

Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of your profession.  As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your profession's standards.  

For Planning Committee disclosures, please see the statement above.  For speaker disclosures, please see the faculty biography.


* Credit Note - ---

Earn up to 2.0 CE hours. Please see below, for more details, as credit amounts vary by state and profession. 


Nurses - Nurses, Nurse Practitioners, and Clinical Nurse Specialists - ANCC

PESI, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Nurses completing these self-study materials will earn 2.0 contact hours. Expires: 08/08/2026.


Nurses - California Nurses

PESI, Inc. is a provider approved by the California Board of  Registered Nursing, Provider #: 17118 for 2.0 self-study contact hours. 

** You will need to provide your license number to PESI. PESI must have this number on file in order for your hours to be valid.


Nurses - Florida Nurses

PESI, Inc. is an approved provider by the Florida Board of  Nursing. Provider #: FBN2858. These materials qualify for 2.0 self-study contact hours.

CE Broker


Nurses - Iowa Nurses

PESI, Inc. is an approved provider by the Iowa Board of Nursing. Provider #: 346. Nurses successfully completing these self-study materials will earn 2.0 self-study contact hours. Please email cepesi@pesi.com with your license number, include the title, speaker name and date. PESI must have this number on file in order for your hours to be valid.


Other Professions

This self-study activity qualifies for 2.0 continuing education clock hours as required by many national, state and local licensing boards and professional organizations. Save your activity advertisement and certificate of completion, and contact your own board or organization for specific requirements.



Handouts/Brochure

Speaker

Rachel Henderson, PhD, MS, RN, HCRM's Profile

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


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.


Additional Info

Access for Self-Study (Non-Interactive)

Access never expires for this product.


Questions?

Visit our FAQ page at www.pesi.com/faq or contact us at www.pesi.com/info


Objectives

  1. Compare and contrast a medical error and a medical mistake.
  2. Discuss components of a medical malpractice claim.
  3. List outcomes associated with proper medical documentation.
  4. Explain common errors in medical records.
  5. Analyze documentation errors and mistakes and cite appropriate corrective actions.

Outline

Medical Errors v. Medical Mistakes
  • differentiate between medical errors and medical mistakes
  • Examples of medical errors
  • Examples of medical mistakes
  • What is medical malpractice?
What is Medical Malpractice?
  • Key elements of a malpractice cause of action lawsuit
  • Define Standard of Care
  • Acts of omission
  • Liability Exposure
Proper Medical Documentation
  • Communicate with other medical personnel
  • Minimize exposure to risk management
  • Documents, quality measures, and CMS hospital indicators
  • Provides proper reimbursement
Common Errors in Medical Records
  • Errors in transcription
  • Misuse of abbreviations
  • Insufficient documentation
  • Ignoring crucial information
  • Incorrect information entry
  • Other medical errors
Examples of Documentation Errors and Mistakes

Target Audience

  • Nurses
  • Nurse Practitioners 

Reviews

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