Seminar Detail

Nursing Documentation: Proven Strategies to Keep Your Patients and Your License Safe
Nursing Documentation: Proven Strategies to Keep Your Patients and Your License Safe

When:  Thursday, March 23, 2017 at 8:00 AM - 4:00 PM

This event is no longer available for purchase.

Other ways to Register: Call (800) 844-8260  
Course Description
Join expert and legal nurse consultant, Rosale Lobo, to learn how to develop a systematic approach to documentation that will keep you, your patients and your license safe. You will learn how to identify and avoid risky documentation as well as how to correctly utilize electronic documentation and the correct technique for meaningful use. Rosale will show you, step by step, how to overcome your most complex documentation questions and challenges.

This dynamic one-day program will include tools to improve your documentation including:
  • Time-saving tips for electronic documentation and EMR use
  • Documenting compliance, incident reports, and adverse events
  • Sample strategy worksheets for ease of data collection
  • Federal government requests for charting based on meaningful use criteria
  • Dangers with social media, email, and texting
  • Examples and case studies of correct and incorrect documentation
If there is no CE tab, please refer to the course brochure (on the Details tab) for continuing education information.
Learner Objectives:

  1. Identify a strategic nursing documentation system.
  2. Describe how documentation is used to decide if you are guilty or innocent in a lawsuit.
  3. Recognize the meaningful use criteria to meet reimbursement needs.
  4. List how to best use features in computerized records to ensure reimbursement.
  5. Identify how to prevent risky behavior when using social media and other forms of electronic communication.
  6. Define how to use best practice and standard of care for documenting incident reports and adverse events.
  7. Integrate the correct practices into your documentation to keep your license unblemished.
  8. Summarize the common documentation mistakes and how to avoid and/or correct them.
Program Outline

  • The Components of Documentation
    • Guidelines
    • Interpretation
    • Mistakes
    • Education
    • Social Networking
    • Indirect Care
  • Electronic Nursing Documentation
    • American Recovery and Reinvestment Act
    • Meaningful Use
    • Health Insurance Portability and Accountability Act (HIPPA)
    • Risky electronic documentation practices
    • Dangers of email, social networking, and texting
  • Electronic Medical Records (EMR) Strategies
    • Time Management
    • Liability
    • Software Knowledge
    • Meaningful Use
  • Reimbursement and Documentation
    • Medicare/Medicaid Changes
    • Incentives and meaningful use criteria
    • EMR Timelines
    • Hospital Acquired Conditions
  • Documentation When Things Go Wrong
    • Compliance
    • Regulations
    • CMC
    • Incident Reports
    • Adverse Events
    • Risk Factors
  • Ethical Issues
    • Truth Tellers
    • Standards
    • Deviations
    • Errors
    • Omissions
    • Communicating
    • Corrections
  • 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
    • Depositions
  • Examples and Case Studies of Documentation


Rosale Lobo has 30 years of combined experience as a direct care nurse, faculty, administrator, and legal nurse consultant. Rosale is a staff nurse at a large teaching hospital in Connecticut and serves as clinical faculty at Southern Connecticut State University. She began working with attorneys in North Carolina and expanded her independent legal nurse consulting practice to New York, Georgia, Colorado, and Connecticut. Plaintiff medical malpractice attorneys have utilized her expertise as both an expert witness and a "behind-the-scenes" consultant.

Rosale is a BSN graduate from Long Island University, Brooklyn, New York (1986) and she graduated magna cum laude with her master's degree from Hunter College, New York. Rosale currently attends Walden University in the School of Public Policy and Healthcare Administration, completing her dissertation research on Nursing Documentation Policy. Rosale is the author of Guilty or Innocent, Protecting Your License Through Proper Nursing Documentation (PHC Publishing Group, 2012). She is a member of the American Nurses Association, American Association of Legal Nurse Consultants, past educational board member for the Connecticut Association of Legal Nurse Consultants, and the American Society of Public Administration.

Speaker Disclosures:

Financial: Rosale Lobo is an Adjunct Clinical Faculty for Southern Connecticut State University and Gateway Community College. She receives royalties as an author for PESI Publishing & Media. Ms. Lobo receives a speaking honorarium from PESI, Inc.

Nonfinancial: Rosale Lobo has no relevant nonfinancial relationship to disclose.
American Nurses Credentialing Center Logo
PESI, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses in full attendance will earn 6.3 contact hours. PARTIAL CONTACT HOURS WILL BE AWARDED FOR PARTIAL ATTENDANCE.

This educational offering has been reviewed by the National Continuing Education Review Service (NCERS) of the National Association of Long Term Care Administrator Boards (NAB) and approved for 6 clock hours and 6 participant hours.

This activity qualifies for 380 minutes of instructional content as required by many national, state and local licensing boards and professional organizations. Save your course outline and certificate of completion, and contact your own board or organization for specific requirements.

Credit Card Required for online registration | Contact us to redeem Gift Certificates