This seminar is designed for registered nurses, LPNs, directors of nursing, administrators, nurses’ assistants, nursing technicians, medical records directors, physician assistants, personal care providers and attorneys.
Documentation is probably one of the most critical areas for health care.
“If it is not documented, it is believed you didn’t do it.” Even if you performed tasks, if the information is not written in the patient record it is perceived that the action was not performed.
Inadequate documentation has become the basis of litigation in many cases. Failure to adequately document may lead to allegations of malpractice or affect your license to practice. It is important for the record to be clear, complete, concise, and accurate. Information needs to be recorded in an effective and timely fashion.
Topics to be discussed include:
• Elements Of A Malpractice Action
• Documentation Pitfalls
• Charting Defensibly
• Interplay Of Documentation In The Progression Of A Lawsuit
9:00 a.m. - 10:00 a.m.
A. All Documentation Is Important From A Medical/Legal Standpoint
1. Initial/Triage Document
2. Flow Sheets
4. Progress Records
5. OR Records
6. Incident Reports
7. Consent Documents
B. Special Unit And Unique Area Issues
C. Charting Spectrum – Maintenance Care To Code Situation
10:00 a.m. - 10:30 a.m.
II. Elements Of A Malpractice Action
C. Injuries And Damages
D. Differentiation From Informed Consent
10:30 a.m. - 10:45 a.m.
10:45 a.m. - 12:15 p.m.
III. Documentation Pitfalls
A. Incomplete Charting
C. Late Notes
D. Charting By Exception
E. Conclusory Recharting
F. Inconsistent Charting
12:15 p.m. - 1:15 p.m.
Lunch (On Your Own)
1:15 p.m. - 2:15 p.m.
IV. Charting Defensibly
A. Contemporaneously Charting
B. Legible Charting
C. Objective Charting
D. Consistency In Terminology In Charting
E. Charting Consistency With Hospital Or Facilities Policies And Procedures
2:15 p.m. - 3:15 p.m.
V. Interplay Of Documentation In The Progression Of A Lawsuit
A. Precipitating Event
B. Statute Of Limitations
C. Pre-Filing Requests And Communications Prior To Filing
3:15 p.m. - 3:30 p.m.
3:30 p.m. - 4:30 p.m.
VI. Case Studies And Documentation