Image of Nursing Documentation: Legally-Proven Strategies to Keep You Out of th
Digital Seminar

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


Faculty:
Rachel Cartwright-Vanzant
Duration:
6 Hours 14 Minutes
Format:
Audio and Video
Copyright :
Aug 15, 2013
Product Code:
POS013130
Media Type:
Digital Seminar


Description

Course Description:

If you were required to testify in court in defense of the care you provided to a patient, would your documentation be adequate to protect you from legal liability? If the care you provided came under scrutiny months or years after it occurred, would your documentation enable you to accurately describe the standard of care delivered to the patient? If you are not sure, then you do not want to miss this program!

During this in-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, an independent legal nurse consultant with over 28 years of clinical, management and consulting experience, will provide you with the information you need to ensure that your documentation, whether hand-written or electronic, depicts a level of care that meets applicable standards.

Learn how to identify and avoid risky documentation and integrate practices that will keep your license unblemished. What you learn will be immediately applicable to your practice and may keep you out of the courtroom.

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.

 

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

 

ADA Needs

We would be happy to accommodate your ADA needs; please call our Customer Service Department for more information at 1-800-844-8260.

 

Satisfaction Guarantee

Your satisfaction is our goal and our guarantee. Concerns should be addressed to: PO Box 1000, Eau Claire, WI 54702-1000 or call 1-800-844-8260.

Credits


**

NOTE: Tuition includes one free CE Certificate (participant will be able to print the certificate of completion after completing and passing the on-line post-test evaluation). 

Continuing Education Information:  Listed below are the continuing education credit(s) currently available for this non-interactive self-study package. Please note, your state licensing board dictates whether self-study is an acceptable form of continuing education. 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 cepesi@pesi.com or 800-844-8260 before the event.

Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals.  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 professions standards


California Nurses

PESI, Inc. is a provider approved by the California Board of  Registered Nursing, Provider #: 17118 for 6.0 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.


Florida Nurses

CE Broker

PESI, Inc. is an approved provider by the Florida Board of  Nursing. Provider #: FBN2858. These materials qualify for 6.0 self-study contact hours.


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 7.6 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 6.25 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

Faculty

Rachel Cartwright-Vanzant Related seminars and products: 6

PhD(c), MS, RN, LHRM, LNCC, CCRN-K


Rachel Cartwright-Vanzant has over 28 years of clinical, management and consulting experience. Rachel is a legal nurse consultant certified (LNCC) and a licensed healthcare risk manager (LHRM), and she holds a forensic nurse certificate (FNC). In addition to owning a medical and legal consulting business, she is currently enrolled in the Public Policy and Administration: Law and Policy PhD Program at Walden University. Rachel is an innovative educator committed to advancing the field of nursing. She is a member of the National Speakers Association and the Global Speakers Federation. Rachel has the ability to make complex concepts understandable and clinically useful, which adds significant value to her presentations.

Rachel's nursing experience includes work in critical care, renal transplant, dialysis and surgical areas. She has extensive experience in open-heart surgery recovery (OHSR) and was responsible for developing and implementing a new cardiothoracic program's first OHSR plan from the ground up. As a legal nurse consultant, Rachel works with attorneys, law firms and healthcare organizations to review and evaluate medical records for compliance with standards of care and regulations posed by accreditation agencies, including The Joint Commission. She is the President of the South Florida AALNC Chapter and has been an expert witness for medical negligence cases. She is a published author in textbooks and peer reviewed journals and continues to speak nationally on other healthcare related topics.

Disclosures:
Financial: Rachel Cartwright-Vanzant is receiving a fee for speaking at this educational activity.
Nonfinancial: Rachel Cartwright-Vanzant has no relevant nonfinancial relationships to disclose. 


Additional Info

Program Information

Access for Self-Study (Non-Interactive)

Access never expires for this product.


Target Audience

Nurses, Nurse Practitioners, Clinical Nurse Specialists, Legal Nurse Consultants, Risk Managers, Nursing Home Administrators

Reviews

5
4
3
2
1

Overall:      4.3

Total Reviews: 6

Satisfaction Guarantee
Your satisfaction is our goal and our guarantee. Concerns should be addressed to: PO Box 1000, Eau Claire, WI 54702-1000 or call 1-800-844-8260.

ADA Needs

We would be happy to accommodate your ADA needs; please call our Customer Service Department for more information at 1-800-844-8260.

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