Product Detail

Nursing Documentation: Legally-Proven Strategies to Keep You Out of the Courtroom
Institutional
$1,000.00 USD
Product Details
Format:
Institutional - License - 1 Year   Instructions
Details:
Multi-disc DVD recording (6 hours, 14 minutes) with electronic manual and instructions.
Author:
RACHEL CARTWRIGHT-VANZANT, PHD, MS, RN, LHRM, LNCC, CCRN-K
Publisher:
PESI HealthCare
Copyright:
8/15/2013
CE Available:
Yes, See CE credit tab for complete continuing education details
Product Code:
IKIT013130
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
Author

RACHEL CARTWRIGHT-VANZANT, PHD, MS, RN, LHRM, LNCC, CCRN-K

Rachel Cartwright-Vanzant, MS, RN, CNS, LHRN, LNCC, has nearly three decades of clinical, management and consulting experience. Rachel is a legal nurse consultant certified (LNCC), a licensed healthcare risk manager (LHRM) and she holds a forensic nurse certificate (FNC). 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. In addition to her legal insights, Rachel draws from vast clinical experiences, including work in: critical care, renal transplant, dialysis and surgical settings. Speaker Disclosures:

Financial: Rachel Cartwright-Vanzant is the Owner of Medical Legal Concepts, LLC. She is an Adjunct Instructor for the School of Nursing at Palm Beach State College. Ms. Cartwright-Vanzant receives a speaking honorarium from PESI, Inc.

Nonfinancial: Rachel Cartwright-Vanzant has no relevant nonfinancial relationship to disclose.
Continuing Education Credits

Nurses/Nurse Practitioners/Clinical Nurse Specialists - Credit Expired: 8/15/2016
No CE available for this board.

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:
Florida
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 6.3 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.


Other Professions
This self-study activity qualifies for 6.25 clock hours of instructional content as required by many national, state and local licensing boards and professional organizations. Retain your certificate of completion and contact your board or organization for specific filing requirements.

Disclaimer: **Information obtained in this course should be used within your scope of practice.
**It is your ethical responsibility to report accurate hours to your licensing board.
**All self-study participants must complete and pass (80% or better) a post-test/evaluation prior to receiving a certificate of completion. If you require a copy of the test/evaluation for CE purposes, please print at the time you take the test. Or you may call our customer service department and a copy of your test/evaluation will be emailed to you. Please allow 30-45 days.


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