Product Detail

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.

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

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.

For U.S. and Canadian customers, CE is available for $20.00 USD per participant. International CE rates may vary; please contact our Customer Service at 1-800-844-8260 for more details.

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.

Certificates of Successful Completion will be emailed, faxed or mailed to participants completing the post-test/evaluation and paying the CE fee.

**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.

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.

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Nurses/Nurse Practitioners/Clinical Nurse Specialists - Credit Expired: 8/15/2022
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: 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.

Copies of the evaluation may be sent to the IBON. 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.

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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 and 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.

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