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Defensive Charting For Nurses Course

Defensive Charting For Nurses Course - In this course, you will also understand documenting phone calls, the legalities of charting, and. The importance of creating a clearly defined plan of care with interprofessional goals and strategies is critical to ensuring documentation is defensible to. Compare and contrast documentation formats. This training course is intended to cover the knowledge and principles of good record keeping. You’ll leave this course with a broader understanding of what effective charting looks like, as well as ineffective charting. Understanding and utilizing best practice of accurate defensive documentation will help avoid allegations of misconduct by way of misinformation. Here is some information that can assist with improving your charting and reducing liability risks: The concepts of skilled, reasonable, and necessary will be articulated in terms nurses and therapists will understand. Cynthia will share her knowledge of how documentation is used in the legal arena with examples of common documentation pitfalls. One tool especially suited for defensive documentation is the acronym fact, which stands for factual, accurate, complete, and timely.

For example, to meet standards related to evaluating a patient’s progress towards goals, the nurse and others on the healthcare team need to review past documentation. This course will examine the technical and clinical criteria for skilled nursing facility coverage and the core principles of documentation. This course will update nurses on the requirements of medical record documentation as well as professional, responsible documentation strategies. Tips for passing medicare audits, charting incident reports and writing physicians’ orders accurately will all be discussed. When documenting, record only information and behavior you observe. Chart any procedures you do and patient response, chart pain and pain meds. This course will take you through the daily charting and documentation that is necessary for your patients. List three problem areas in nursing documentation. One tool especially suited for defensive documentation is the acronym fact, which stands for factual, accurate, complete, and timely. This class will engage both experienced and n ewer nurses.

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The Importance Of Creating A Clearly Defined Plan Of Care With Interprofessional Goals And Strategies Is Critical To Ensuring Documentation Is Defensible To.

When documentation becomes your defense; You’ll leave this course with a broader understanding of what effective charting looks like, as well as ineffective charting. Armed with a fundamental understanding of this information, clinicians will be able to meet documentation expectations. List three problem areas in nursing documentation.

This Course Will Update Nurses On The Requirements Of Medical Record Documentation As Well As Professional, Responsible Documentation Strategies.

~ legal lingo ~ general documentation tips ~ narrative note writing ~ incident report writing ~ crisis standards of care Facilitated by registered nurses with first hand clinical experience, this ½ day blended learning course allows attendees to gain theoretical and practical pressure area care knowledge. Avoid value judgments, bias, labels, and subjective opinions. This course will take you through the daily charting and documentation that is necessary for your patients.

At Its Core, Documentation Should Provide A Nurse With An Indisputable Defense Against Malpractice.

Examples of good and bad charting; Describe two documentation strategies to reduce liability exposure. For example, to meet standards related to evaluating a patient’s progress towards goals, the nurse and others on the healthcare team need to review past documentation. When documenting, record only information and behavior you observe.

Chart Any Procedures You Do And Patient Response, Chart Pain And Pain Meds.

Here is some information that can assist with improving your charting and reducing liability risks: The concepts of skilled, reasonable, and necessary will be articulated in terms nurses and therapists will understand. Cynthia will share her knowledge of how documentation is used in the legal arena with examples of common documentation pitfalls. Tips for passing medicare audits, charting incident reports and writing physicians’ orders accurately will all be discussed.

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