Nursing Documentation: Legally-Proven Strategies to Keep You Out of the Courtroom - Rachel Cartwright-Vanzant

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Nursing Documentation: Legally-Proven Strategies to Keep You Out of the Courtroom – Rachel Cartwright-Vanzant

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The course: Nursing Documentation: Legally-Proven Strategies to Keep You Out of the Courtroom by Rachel Cartwright-Vanzant

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Faculty:
Rachel Cartwright-Vanzant
Duration:
6 Hours 14 Minutes
Format:
Audio and Video
Copyright:
Aug 15, 2013

Description

Printable Materials (18.5 MB) Available after Purchase

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

Faculty

Rachel Cartwright-Vanzant, MS, RN, CNS, LHRN, LNCC Related seminars and products: 7

Rachel Cartwright-Vanzant, MS, RN, CNS, LHRN, LNCC, has nearly three decades of clinical, management and consulting experience. Rachel is a legal nurse consultant certified (LNCC), a licensed healthcare risk manager (LHRM) and she holds a forensic nurse certificate (FNC). As a legal nurse consultant, Rachel works with attorneys, law firms and healthcare organizations to review and evaluate medical records for compliance with standards of care and regulations posed by accreditation agencies, including The Joint Commission. In addition to her legal insights, Rachel draws from vast clinical experiences, including work in: critical care, renal transplant, dialysis and surgical settings.

Disclosures:
Financial: Rachel Cartwright-Vanzant is receiving a fee for speaking at this educational activity.
Nonfinancial: Rachel Cartwright-Vanzant has no relevant nonfinancial relationships to disclose.

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