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1. Create a strategic nursing documentation system.
2. Theorize how documentation is used to decide if you are guilty or innocent in a lawsuit.
3. Determine the meaningful use criteria to meet reimbursement needs.
4. Categorize how to best use features in computerized records to ensure reimbursement.
5. Evaluate how to prevent risky behavior when using social media and other forms of electronic communication.
6. Utilize best practices and standards of care for documenting incident reports and adverse events.
7. Integrate the correct practices into your documentation to keep your license unblemished.
8. Determine 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

Brenda Elliff, RN, MPA, ONC, CCM, LNCC, established Elliff Medical-Legal Services in 1996. As a legal nurse consultant, she assists on both plaintiff and defense cases. She performs record reviews, develops strategies and provides expert witness preparation. Her work involves Medical Malpractice, Worker’s Compensation, Personal Injury and a variety of legal cases. Previously, Brenda worked as a Health Care Coordinator for a large law firm and taught a Legal Nurse Consultation review course. Initially, she began working with attorneys on legal cases in California and has now expanded her scope throughout the Pacific NW.

Her clinical nursing experiences are vast and span 40 years. Brenda has worked as a staff nurse, as a nurse manager at major teaching facilities, as nurse case manager and as an adjunct nursing professor.

When not nursing, Brenda enjoys participating with a local performing group. The group has performed at the LA Christmas Parade, 75th Anniversary of Pearl Harbor Parade in Honolulu and the Washington DC Cherry Blossom Parade. Past nurses who have attended Brenda’s programs have appreciated the dynamic and fun way in which she can deliver excellent clinical and legal information. She has been a sought-after speaker at national, state and local levels, on a variety of topics that draw from her areas of expertise. Speaker Disclosures:

Financial: Brenda Elliff maintains a private practice. She receives a speaking honorarium from PESI, Inc. She has no relevant financial relationships with ineligible organizations.

Nonfinancial:Brenda Elliff has no relevant non-financial relationships to disclose.

Save time and $10 off the price of other submission methods – purchase & take the CE test online for $19.99 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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Ethics
This self-study course includes 2.5 hours of general ethics instruction. Not all boards allow ethics credit for self-study products. If ethics is not specified within your licensing board’s approval statement below, please contact your board to determine the applicability and amount of ethics allowed.

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Nurses, Nurse Practitioners, and Clinical Nurse Specialists
This self-study activity consists of 6.25 clock hours of continuing education instruction. Credit requirements and approvals vary per state board regulations. Please save the course outline, the certificate of completion you receive from this self-study activity and contact your state board or organization to determine specific filing requirements.

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