Catalog Number : ngd1010
Title : Documentation Requirements in Your Hospital - Part 1
Speaker : Sue Dill

Webplay Recording Date : 4-15-2009
Webplay Price : $ 225 for two weeks viewing

Webinar Overview:

This Webinar is a must attend for any nurse who works in health care today. Your Speaker Sue Dill will discuss the importance of documentation to avoid allegations of malpractice, substandard care and denial of reimbursement. This is especially important in light of the new 2008 CMS regulations on adverse events in which documentation must be present on admission (POA) to receive full reimbursement. Good concise documentation is also the key to preventing claims of fraud and abuse.

This Webinar will help improve documentation skills. The Webinar will focus on the Joint Commission Standards and CMS hospital regulations on documentation. It will cover tips to improve documentation, case examples, and nursing documentation guidelines and standards. Each attendee will receive an electronic copy of the slides, sample forms and policies, and many additional useful resources.

Target Audience:

• Physicians
• Nurse Educators
• Nurses
• Risk Managers
• Hospital Attorneys
• Compliance Officers
• Quality and Performance Improvement Coordinator
• Chief Nursing Officer
• Patient Safety Officer
• Joint Commission Coordinator
• Nurse Managers
• Pharmacy Staff
• Policy and Procedure Committee Members
• Case Managers
• Nurse Supervisors
• Medication Team Members
• Patient Safety Committee Members
• Others who participate in the medication process should attend

Webinar Objectives:

• Discuss two recommendations for documentation that can reduce liability
• What to document to comply with the Joint Commission organ donation standards such as the one call rule for all deaths

The following are a few of the topics to be discussed:

• Legal issues in documentation admissibility
• Fading memories
• 40 tips to improve documentation based on case law
• Record date/time
• Legibility
• Restraints
• Safeguards to protect patient
• Spelling
• Abbreviations
• Charting by exception
• Code charting
• Joint commission resuscitation standards
• Patient non-compliance
• AMA & EMTALA requirements
• Omitted or late entries
• Medication
• Emergency department (ENA) documentation standards
• Operating room (AORN) documentation standards
• PACU documentation standards
• Legal issues in computerized records incident reports
• Patient education
• Discharge instructions
• Pain
• Reason for test
• Medical necessity
• Observation
• Advance beneficiary notice
• NPO AND I&O
• Joint commission & medical records audit tool
• Patient call-backs
• Observation & documenting information for quality improvement
• Joint commission organ donation standards (ld 3.110)
• IV standards
• Care plan
• Medication reconciliation
• Allergies
• Phone calls
• Nutrition
• Hydration
• Date & time of order
• Procedures
• Domestic violence
• Chain of command
• Infection control
• Role of nursing process
• Prescriptions
• Pressure ulcers & VAP

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.