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
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 has worked as an inpatient clinical nurse specialist. As such, she has been integral to the most at-risk patients. She draws from over thirty years of clinical, educator and consulting roles for the assurance of quality of patient care and safety.

Rachel is licensed as a health care risk manager and provides expert witness testimony in civil court cases regarding patient care issues that come under legal scrutiny when standards of care are challenged. Rachel's seminars incorporate not only the best clinical practice standards but include real litigation examples.

Viewed by her colleagues as an extremely skilled speaker, she possesses the unique ability to transform challenging topics into engaging and practice-changing events. This expertise has been sought to educate healthcare professionals all across the country. 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.


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