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

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, PhD, RN, MSN, LNC, has been a registered nurse for 37 years in the capacity of a direct care provider, administrator, researcher, speaker, author, legal nurse consultant, and entrepreneur. Working with people in hospitals, clinics, and home care settings allowed her to study patients and healthcare policy and administration. Her dissertation grew from the love of researching healthcare standards as a legal nurse consultant. Her company, Lobo Consulting Group, LLC partners with medical malpractice attorneys to support their pursuit of justice for their clients. Through her versatile background, she has acquired expertise in the nuances and complexities of healthcare litigation and documentation. As a speaker, Dr. Lobo continues to travel the country speaking with nurses and healthcare systems about the pathways to safer practice patterns.

Speaker Disclosures:
Financial: Rosale Lobo has an employment relationship with Southern Connecticut State University. She receives a speaking honorarium and recording royalties from PESI, Inc. She has no relevant financial relationships with ineligible organizations.
Non-financial: Rosale Lobo has no relevant non-financial relationships.

Save time and $10 off the price of other submission methods – purchase & take the CE test online for $9.99 USD per participant. Additional processing fees apply for other submission methods (i.e. mail, fax, etc.). 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 are available for email, download and/or printing from your online account immediately following the successful completion of the post-test/evaluation.

**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: 5/10/2022
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