Webinar Purpose:

This seminar is a must attend program for any nurse working in healthcare today. It will discuss the importance of documentation to avoid allegations of malpractice, substandard care, accreditation nightmares and denial of reimbursement. Good concise documentation is the key to preventing claims of fraud and abuse.

This program will help improve documentation skills. It will discuss legal issues in documentation, and Joint Commission and CMS hospital CoP issues related to documentation requirements. It will provide over 40 recommendations to improve documentation.

This program will also include some things hospitals should do and document to prevent unnecessary readmissions. Hospitals that have a higher than average rate of readmission are being financially penalized by CMS. This program will discuss how to document to comply with the CMS regulation on visitation and will help hospitals as they move toward an electronic medical record to discuss some of the CMS and TJC documentation requirements that should be entered as a field.

Webinar Objectives:

• Discuss two recommendations/tips to improve documentation that will reduce the risk of liability
• Explain the importance and what should be documented in the assessment of pain
• Describe what TJC has in the Record of Care chapter; including things that must be documented in medical records
• Explain the CMS requirement that all orders must be in writing on the order sheet even if hospitals use approved protocols
• Discuss that both CMS and Joint Commission have standards that require specific documentation of verbal orders

Target Audience:

Chief Executive Officer (CEO), Chief Operating Officer (COO) Chief Nursing Officer (CNO), Nurse Managers, All Nurses, Nursing Supervisors, Compliance Officer, Joint Commission Coordinator, Quality Improvement Coordinator, Clinic Directors, Consumer Advocates, RAC coordinator, compliance officer, director of regulatory affairs, physicians, Risk Managers, Patient Safety Officer, Staff Nurses, Nurse Educators, Department Directors, Chief Medical Officer (CMO), physicians, Legal Counsel, Documentation Specialist, Health Information Management Director and staff, department directors, PI director and staff and anyone involved in the documentation process

Webinar Outline:

• Introduction
• Charting bloopers
• Admissibility of medical records
• Fading memories
• Use of checklists
• 40 tips to improve documentation based on case law
• Why document
• Record date/time
• Legibility and doctors signature must be legible on all orders
• Recording name of care giver
• Charting all nursing actions
• Safeguards to protect patient
• Objective documentation
• RAC and documentation issues
• 2 midnight rule and certification and medical necessity
• Joint Commission Record of Care Chapter requirements
• Spelling
• Late entries
• Amendments
• HIPAA amendment requirements
• CMS preprinted orders
• CMS standing orders
• Documenting for others
• Countersigning
• CMS and TJC Informed Consent
• Medication management documentation
• Signing your chart properly
• Abbreviations
• Code charting
• Joint Commission new documentation chapter
• CMS and TJC Verbal order documentation
• CMS informed consent
• Avoid vague expressions
• Documenting telephone orders
• Patient non-compliance
• Observation patients
• Omitted or late entries
• Complete medication information
• Incident reports
• Interpreters
• Pain assessments
• PCA and documentation of information
• Patient education documentation
• Discharge instructions and preventing readmission
• Document chain of command
• Document OR checklist
• Time Outs
• Plan of care (TJC and CMS problematic standard)
• Skin assessment/skin tears
• Circulation checks
• Fall assessment
• IV documentation
• Admission assessments
• Code charting
• NPO status and I&O
• Abnormal X-ray and lab results
• Advance directives
• Documenting to comply with CMS Visitation standard

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.