Catalog Number : ngd1011
Title : Documentation Requirements in Your Hospital - Part 2
Speaker : Sue Dill

Webplay Recording Date : 4-22-2009
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:

• Describe changes to the hospital CoPs
• Why you must rewrite your policies and medical staff by-laws
• List what should be documented to comply with EMTALA

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

• Documenting the CMS Patient Rights Standards Restraint and Seclusion
• Notice of patient rights
• Grievance process
• Refusal of care
• Interpreters
• Advance directives
• Confidentiality of medical records
• CMS vs. Joint Commission restraint standards
• CMS Regulations for Medical Records Verbal orders
• Content of record
• Informed consent
• Legibility & authentication
• History & physical
• Final diagnosis
• Form & retention of record
• New changes to History and Physicals
• Verbal orders effective 1-26-07 & 1-1-08
• Documentation to Comply with EMTALA
• Overview of EMTALA
• EMTALA enforcement guidelines
• Medical screening exam
• “Comes to your Hospital ED”
• Stabilization
• Refusal of care & Signing out AMA

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.