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Product Detail

Nursing Documentation: Legally-Proven Strategies to Keep You Out of the Courtroom
DVD Video
$219.99 USD
Product Details
Format:
DVD Video - 4+ hours   Instructions
Length:
6 hr 14 min
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:
RNV013130
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, Ph.D., MS, LHRM, CCRN-K is an innovative educator using effective strategies to help nurses to easily understand complex concepts to avoid patient crisis. She is a legal nurse consultant, licensed healthcare risk manager and published author in peer reviewed journals. Her clinical insights have been sought to evaluate medical records for compliance with standards of care, including medication errors. Rachel delivers more than basic textbook information, because her presentations tap into her extensive experience in various clinical care roles. She is known in the healthcare industry as a patient safety expert, delivers keynote speeches, and provides expert witness testimony in court regarding nursing care and documentation deficiencies. Rachel connects immediately with her audience, because her humor and entertaining presentation style turns seemingly boring topics into fun conversations. 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
For U.S. and Canadian customers, CE is available for $20 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.

The planning committee and staff who controlled the content of this activity have no relevant financial relationships to disclose. For speaker disclosures, please see speaker bios.


Nurses, Nurse Practitioners, and Clinical Nurse Specialists - Credit Available Until: 8/15/2022
American Nurses Credentialing Center Logo
PESI, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation. Nurses completing these self-study materials will earn 6.3 contact hours. Expires: 8/15/2022.

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.

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.


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